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A MULTIDIMENSIONAL APPROACH TO THE STUDY OF PRENATAL COCAINE 

EXPOSURE 



- 



08^ 



v ^ 




CARLA DENISE ARMBRISTER EDWARDS 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT 

OF THE REQUIREMENTS FOR THE DEGREE OF 

DOCTOR OF PHILOSOPHY 

UNIVERSITY OF FLORIDA 

2001 



Copyright 2000 

by 

Carl a Denise Armbrister Edwards 



This research was supported by two grants (5RO1DA05854-08 and R2961444-12) from 
the National Institute on Drug Abuse administered through the Department of Pediatrics 
in the College of Medicine at the University of Florida. I extend special thanks to Fonda 
Davis Eyler, Ph.D., the principal investigator and Marylou Behnke, the co-principal 
investigator, for providing me with the opportunity to work with them on this project. 









ACKNOWLEDGMENTS 

It is difficult to know where to begin with my acknowledgements. I have been 
blessed with a large and active support network. I am forever grateful to Dr. Barbara 
Zsembik, my dissertation chair. She has provided me with guidance, motivation, and 
wisdom. I am especially thankful to Dr. Leonard Beeghley, Dr. Terry Mills, and Dr. 
John Henretta, my committee members. I truly appreciate how they always required 
more and how they anticipated the best from me at all times. I express sincere 
appreciation to Dr. Fonda Davis Eyler and Dr. Marylou Behnke for inviting me to serve 
on their research team, for mentoring me, and for providing me with numerous 
opportunities to enhance my research skills and experience. 

Also, I must acknowledge the women and children who have permitted the 
research team to delve into their lives over the past ten years. I hope the results of this 
research will serve to enhance the quality of life for the many women and children who 
are struggling to cope with their mere existence on this planet. 

This dissertation would not have come to fruition without the love and support of 
my husband, Herman Edwards and my parents, Anthony and Juanita Armbrister. Over 
the past four years, my immediate and extended family has encouraged me to finish my 
degree while helping me cope with the loss of many loved ones (including the loss of my 
only sibling). The encouragement, love, and support I have received from this large 
group of people, including two grandmothers, aunts, uncles, and cousins, is 
immeasurable. 



IV 



Last, I am thankful for my Aunt Priscilla, who read my manuscript, my Uncle 
Rickie, who hugged me and pointed me in the right direction after I lost my manuscript, 
my dear friend Yvonne, who helped me find it again, and my Aunt Lucille, who delivered 
it to the graduate school for first submission. Along with several other angels, these folks 
were all in the right place at the right time. 









TABLE OF CONTENTS 

page 

ACKNOWLEDGMENTS iv 

LIST OF TABLES « 

LIST OF FIGURES * 

ABSTRACT xi 

CHAPTERS 

1 INTRODUCTION 1 

2 THE STUDY OF PRENATAL COCAINE EXPOSURE 7 

Literature On Prenatal Cocaine Exposure 7 

Biomedical Research 9 

Behavioral (Psychological) Studies 13 

Sociological Studies 17 

Conclusion 18 



3 MULTIDIMENSIONAL MODEL 20 

Sociological Perspective 21 

Components of the Multidimensional Model 22 

Prenatal Dimension 24 

Neonatal Dimension 24 

Postnatal Dimension 25 

Theoretical Framework 25 

Social Ecological Theory 25 

Resiliency Theory 29 

Definitions Of Behavior And Development 31 

Reason for Studying Pre-Schoolers 32 

Research Questions 33 



VI 



4 RESEARCH VARIABLES AND SAMPLE DESCRIPTION 35 

Data Col lection 35 

Description of Longitudinal Sample and Sample Retention 37 

Description Of Birth Mothers 37 

Characteristics Of Children At Birth 39 

Retention And Attrition At Three Year Follow Up 42 

Operationalization Of Variables and Hypotheses 43 

Prenatal Risk: Prenatal Cocaine Exposure (PCE) 43 

Outcome Measures: Behavior and Development 46 

Neonatal Risk: Newborn Health Status 48 

Postnatal Factors: Social Ecological Model 49 

Summary 57 



5 DATA ANALYSIS AND RESULTS 60 

Analytical Procedures 60 

Differences between PCE children and non-PCE children 62 

Birth Characteristics 62 

Neonatal Environment 63 

Postnatal Environment 65 

Behavior and Development 70 

Environmental Factors and Early Childhood Outcomes 73 

Prenatal Risk and Outcomes 73 

Neonatal Risk and Outcomes 73 

Postnatal Factors and Outcomes 75 

Multidimensional Model of Behavior and Development 80 

Behavior 81 

Development 83 

Summary 86 



6 RISK AND RESILIENCY IN EARLY CHILDHOOD 88 

Early Childhood Risk 88 

Prenatal Cocaine Exposure 88 

Poor Neonatal Health 91 

Maternal Depression 92 

Low Socioeconomic Status 94 

Producers Of Resilience 96 

Positive Parenting 96 

Family and Social Support 97 

Interventions And Implications 98 

Limitations And Recommendations 100 



vu 






LIST OF REFERENCES 

BIOGRAPHICAL SKETCH. 



102 
115 



vm 



LIST OF TABLES 



Table Page 

4. 1: Descriptive Statistics of Biological Mother and Child at Birth by Cocaine Exposure 

Status, Means +/- Standard Deviations (Mean Rank) 39 

4. 2: Longitudinal Study Sample Birth Outcomes by Cocaine Exposure Status, Means +/- 

Standard Deviations (Mean Rank) 40 

4. 3: Subject Retention and Attrition at 3-Year Follow Up 43 

4. 4: Biological Mothers Drug Use by Cocaine Exposure Status, n=308 45 

4. 5: Caregiver's Relationship to Child at Age Three by Cocaine Exposure Status 50 

4. 6: Description of Variables in Multidimensional Model 59 

5. 1: Birth Outcomes by Cocaine Exposure Status, Means+/-Standard Deviations (Mean 

Rank) 62 

5. 2: Postnatal Differences between PCE and non-PCE children at the Microsystem and 

Mesosystem Level, Mean +/- Standard Deviation (Mean Rank) 67 

5. 3: Postnatal Differences between PCE and non-PCE children at the Exosystem and 

Macrosystem Level, Mean +/-Standard Deviation (Mean Rank) 69 

5. 4: Adaptive Behavior and Development by Cocaine Exposure Status, Means +/- 

Standard Deviations (Mean Rank) 72 

5.5: Correlation between Adaptive Behavior and Development, Prenatal Cocaine 

Exposure, and Environmental Factors, Spearman Correlation Coefficient, 
n=234 76 

5. 6: Complete Correlation Matrix, Spearman Correlation Coefficients, n=234 79 

5. 7: Multidimensional Models of Adaptive Behavior and Development, Standardized 

Regression Coefficients (p-values), n=234 83 



IX 



LIST OF FIGURES 

Figure Page 

2. 1: Number of Citations per Discipline Per Year 9 

3. 1: Compensatory and Protective Models of Resilience 29 

3. 2: Multidimensional Model of Behavior and Development 31 

4. 1: Percent of Low Birth Weight Children by Prenatal Cocaine Exposure Status, n=302. 41 

4. 2: Percent of Weeks Cocaine Used During Pregnancy, n=l 15 45 

5. 1: Hobel Complications Scale by Prenatal Cocaine Exposure Status 65 



Abstract of Dissertation Presented to the Graduate School 

of the University of Florida in Partial Fulfillment of the 

Requirements for the Degree of Doctor of Philosophy 

A MULTIDIMENSIONAL APPROACH TO THE STUDY OF PRENATAL COCAINE 

EXPOSURE 

By 

Carla Denise Armbrister Edwards 
December 2001 

Chairman: Barbara A. Zsembik, Ph.D. 
Major Department: Sociology 

OBJECTIVE: Using longitudinal data this research seeks to determine the 
prenatal, neonatal, and postnatal predictors of adaptive behavior and early childhood 
development among children who were prenatally exposed to cocaine. This research 
uses a multidimensional and integrative approach to examine how sociological, 
behavioral, and biomedical factors influence the behavior and development of a group of 
children "at-risk" of poor developmental outcomes. The respective influence of prenatal 
cocaine exposure (PCE), the health status of the infant at birth, the psychosocial status of 
the primary caregiver, the home environment, the families' social supports, and social 
structural variables are included as determinants. 

METHOD: This study utilizes data collected for a longitudinal study on the 
impact of prenatal cocaine exposure on children. The study sample includes 1 15 
prenatally cocaine exposed children and 1 19 controls. The sample is predominantly 
comprised of poor, Black children from single parent households who are "at-risk" of 

xi 






developmental delays because of the problems associated with maternal drug use, a 
typical consequence of social and economic disadvantage. Using bivariate and 
multivariate analysis, this study tests the utility of a multidimensional approach designed 
to contribute to our understanding of the relationship between PCE and the measured 
outcomes. 

RESULTS: The bivariate and multivariate analyses indicate that there is no 
relationship between PCE and the behavioral and developmental outcomes of three-year 
old children. Both behavior and development are significantly correlated with the home 
environment, the families' social support mechanism, and the families' social 
demographics. The quality of the parenting environment within the home is the strongest 
predictor of behavior followed by the families' social demographics and the infant's 
health status at birth. The infant's neonatal health status and the families' social 
demographic were the most significant predictors of development. The multidimensional 
model, which integrates measures of the prenatal, neonatal, and postnatal environments, 
proved to be a stronger model than the prenatal or prenatal and neonatal model combined, 
thus providing evidence that despite the risk associated with prenatal cocaine exposure, 
"at-risk" children exhibit resiliency when placed in positive postnatal environments. 



xn 






CHAPTER 1 
INTRODUCTION 

Children who have been prenatally exposed to crack cocaine have been 
characterized as "at-risk" of exhibiting a variety of developmental and behavioral 
problems (Azuma and Chasnoff 1993; Chasnoff 1988; Chasnoff, Lewis, Griffith, Willey 
1989; Frank, Zuckerman, Amaro, Aboagye, Bauchner, Cabral, Fried, Hingson, Lynne, 
and Levenson 1988; Tronick, Frank, Cabral, Mirochnick, and Zuckerman 1996). 
According to the Robert Wood Johnson Foundation, over 80,000 children will have 
subtle deficits in their intellectual and language development as a consequence of 
prenatal cocaine exposure. These presumed deficits have an anticipated cost to the nation 
of nearly $352 million per year for special education programs (Lester, LaGasse, and 
Seifer 1998). It has not been determined through the use of sound empirical research 
methods whether or not the anticipated and observed problems are a consequence of the 
actual physiological effect cocaine has on the developing fetus and surviving child or the 
social and environmental consequences of being born to a drug addicted mother who may 
have difficulty caring for her child. 

There is a long history of research on the numerous social and environmental 
factors that contribute to children's delayed development and problematic behavior. In 
many of these studies, African-American children are disproportionately considered "at- 
risk" due to the adverse effects of poverty on their health and over all well-being (Federal 
Interagency Forum of Child and Family Statistics 1997; U. S. Department of Health and 



Human Services 1995). Poor children are "at-risk" because of the problems associated 
with family and community disintegration (Kendall-Tackett and Eckenrode 1996; Wilson 
1987) and family violence (Deater-Deckard, Bates, Dodge, and Pettit 1996; Dodge, Pettit, 
Bates 1994; Kendall-Tackett and Eckenrode 1996). Disconcertingly, poverty, family and 
community disintegration, and poor family dynamics are factors that characterize the 
lives of women who abuse drugs and the lives of the children they bear (Coy 1997). 
Consequently, it is difficult to determine whether or not prenatal cocaine exposure or 
some postnatal social environmental factor is responsible for the developmental and 
behavioral problems presumably exhibited by "at-risk" children. 

This study uses an integrative approach to examine the sociological and the 
biomedical determinants of early childhood behavior and development for children 
defined as "at-risk" due to their prenatal cocaine exposure. Specifically, this research 
will address the following: (1) the differences in the behavior and development of 
prenatally and non-prenatally cocaine exposed children and (2) to what extent the 
behavior and development of pre-school aged children is either enhanced or hindered by 
biomedical, behavioral, and sociological factors found in the prenatal and postnatal 
environments. 

Drawing from the health integrative approach advocated for by the Committee on 
Future Directions for Behavioral and Social Sciences Research at the National Institutes 
of Health (Singer and Ryff 2001), I hypothesize that the behavior and development of 
young children are not only dependent on physiological (biomedical) factors derived in 
the prenatal environment, but that they are highly dependent on neonatal factors, such as 
the child's health status at birth and postnatal factors, such as the social structure, social 



support networks, the physical environment, and interpersonal relationships. This study 
seeks to determine the influence of prenatal, neonatal, and postnatal factors on the 
behavior and development of children at age three, a critical stage of maturation in early 
childhood development. 

The predominant belief upheld by popular culture is that children who have been 
prenatally exposed to cocaine are "at-risk" of poor developmental outcomes and that their 
behavioral problems are placing a drain on social, educational, and economic resources 
(Blakeslee 1990; Bragg 1998; Gross 1993; Hinds 1990; Toufexis 1990). The media have 
helped perpetuate this common belief by creating the image of the "crack baby" and the 
out of control drug exposed child or "crack kid." However, much of the scientific 
research on prenatally cocaine exposed children has provided very little evidence that 
cocaine exposed children have any more problems than other children who have survived 
unhealthy prenatal experiences. 

Much of the research on the behavior and development of young children who 
have been prenatally exposed to cocaine has been contradictory and/or inconclusive. 
There are several reasons for the inability of researchers to establish a clear connection 
between prenatal cocaine exposure and subsequent behavior and development. One 
reason is that there are only a few longitudinal studies on prenatally cocaine exposed 
children. Moreover, most researchers are still in the process of collecting and analyzing 
data that include outcome measures for pre-school and school-aged children. Second, the 
majority of studies that have been published have taken a biomedical or behavioral 
approach ignoring the role of social and environmental factors. 



This study is empirically unique in that the data come from a longitudinal project 
funded by the National Institute on Drug Abuse, which contains data for a matched 
control group of prenatally cocaine exposed children from birth through age seven. This 
research addresses the developmental concerns of the children at age three. Furthermore, 
this research is theoretically unique, because it is written from the perspective of a social 
scientist with a multidisciplinary background including training in sociology, 
neuropsychology, counseling, and education. This background predisposes me to 
integrate multiple disciplinary ideas, as I seek to understand how numerous systems 
interact with one another and how these systems influence different aspects of our social 
lives. 

In this research, I raise the question of whether or not prenatal cocaine exposure, a 
consequence of a mother's behavior during pregnancy, is more influential than the 
biomedical health risk determined neonatally and postnatal factors, including 
socioeconomic status, family social support, the home environment, and the primary 
caregiver's psychosocial status. As a social science researcher, I intend to shed light on 
a topic that has been dominated by medical and behavioral researchers. By identifying 
the additive effect of biomedical and social environmental factors associated with 
behavioral and developmental outcomes among "at-risk" children, researchers and 
practitioners can better ascertain the role these factors play in the lives of prenatally 
cocaine exposed children. Then, we can create interventions that may reduce the 
negative impact of the prenatal environment by accentuating the positive attributes found 
in the postnatal environment. 



Using a sociological perspective and the basic tenets of human ecology and 
resiliency theory outlined in Chapter 3, 1 have created a conceptual model that will be 
used to ascertain the effect of the prenatal, neonatal, and postnatal environments on the 
behavior and development of the children included in this research. The compensatory 
model of resilience describes the mechanism by which the neonatal and postnatal 
environments mediate the effect of the prenatal environment on early childhood 
outcomes. The children's prenatal exposure to cocaine represents the prenatal influence 
and the first layer of influence over behavior and development. The neonatal dimension 
is characterized by the newborn's risk of experiencing medically related problems and it 
is related to the outcome. The postnatal dimension is comprised of the social ecological 
systems described in Bronfenbrenner's (1979) ecological model of human development. 
These systems are characterized by the following: (1) the families' sociodemographic 
background, (2) the families' social support system, (3) the home environment, and (4) 
the psychosocial status of the primary caregivers. 

The data in this research come from a matched-control prospective, longitudinal 
study on the effects of prenatal cocaine exposure on fetuses, infants, and developing 
children. The study includes a target group of children whose biological mothers used 
cocaine during their pregnancy and a control group of children whose biological mothers 
did not use cocaine during their pregnancy. During the enrollment that began during the 
pregnancy, for each cocaine user enrolled, a non-cocaine user was enrolled who had 
similar sociodemographic characteristics and prenatal health risks. 

The strengths of the data include the following: (1) the early prenatal enrollment 
of cocaine users and non-users who were matched on numerous social and physiological 



6 

demographics, (2) the repeated drug measures, including oral maternal drug use histories, 
unexpected urine screenings, and confirmation of cocaine exposure through gas 
chromatography/mass spectroscopy, and (3) the use of well trained evaluators who did 
not know the children's cocaine exposure status while conducting the child assessments 
of behavior and development. 

The goal of this research is to examine the problems associated with prenatal 
cocaine exposure using a multidisciplinary approach and an empirically sound research 
design that attempts to avoid the pitfalls found in the existing research on the topic of 
behavior and development of "at-risk" children. The proceeding sections of this report 
include a summary of the existing literature on prenatal cocaine exposure (chapter 2), an 
outline of the multidimensional model used to evaluate behavior and development 
(chapter 3), a detailed description of the research design and sampling procedures 
(chapter 4) and an analysis of the findings (chapter 5) along with their practical and 
theoretical implications (chapter 6). 






CHAPTER 2 
THE STUDY OF PRENATAL COCAINE EXPOSURE 



The image of a drug-exposed infant lying in an incubator connected to lifesaving 
machinery has been reproduced in magazines, newspapers, journals, and on television 
throughout the 1980s and 1990s. The rising number of pregnant cocaine users giving 
birth to prenatally exposed infants and the emotions provoked by these media drawn 
images resulted in the emergence of over 100 scientific studies on the effects of prenatal 
cocaine exposure on women and children (Lester, LaGasse, and Seifer 1998). Based on 
my review of the National Institutes of Health's listing of scientific projects, there are 
over thirty federally funded studies on prenatal cocaine exposure (National Institutes of 
Health 2001). 

In this chapter, I summarize the biomedical, behavioral, and sociological literature 
on prenatal cocaine exposure. The literature that I review denotes the need for more 
studies on prenatally cocaine exposed children that take an integrative or 
multidisciplinary approach. There is an abundance of research on the physiological 
effects of cocaine on fetuses and newborns and a paucity of research on the social 
environmental determinants of early childhood development for this group of children. 

Literature On Prenatal Cocaine Exposure 

My review of the literature on prenatal cocaine exposure consisted of a search of 
library databases using the terms "prenatal cocaine exposure" and/or "cocaine and 
pregnancy." This search resulted in over 800 articles that I have placed in four 



8 

categories: biomedical studies, behavioral (psychological) studies, sociological research, 
and media generated articles. 

I was able to find research articles in (1) Medline, the most popular search engine 
for medically related scientific research, (2) Psyclnfo, a search engine including articles 
related to psychology and the behavioral sciences, (3) Sociological Abstracts and 
Sociofile, two search engines dedicated to social science research, and (4) Lexis-Nexis, a 
search engine that includes international and national newspaper and magazine articles, in 
addition to other sources of information. Due to the nature of computer databases, the 
overlap between databases is inevitable. There were articles in Medline that were also 
available in Psyclnfo and research in Psyclnfo and Medline that may have been covered 
by newspapers and magazines listed in Lexis-Nexis, but this does not lessen the point that 
there were more articles on prenatal cocaine exposure and cocaine use in pregnancy in 
the biomedical and psychological databases than in the sociological databases. 

There were 244 scientific articles in Medline, characterizing a plethora of research 
in the biomedical field. There were 235 articles posted in Psyclnfo compared to only 20 
articles (less than 5%) in the sociological databases, Sociological Abstracts and Sociofile. 
Thus, nearly half of the articles were found in the biomedical and psychologically 
oriented databases with the remaining 40% (n=343) being media generated articles found 
in Lexis-Nexis. In the academic disciplines, the number of articles produced between 
1985 and the year 2000 increased substantially. Between 1990 and 1995 the media's 
interest in the topic reached its peak at 174 articles, outnumbering the articles found in 
Medline (n=101), Psyclnfo (n=l 10), and the sociological databases (n=9). Figure 1 
illustrates the distribution of the literature across each area of interest. 









1985-90 


1990-95 


1996-2000 


Total 


DMedline 


17 


101 


126 


244 


■ Psycinfo 


25 


100 


110 


235 


DSocabs 


1 


9 


10 


20 


□ Media 


83 


174 


86 


343 


■ Total 


125 


384 


332 


842 



DMedline 


■ Psycinfo 


DSocabs 


□ Media 


■ Total 



Figure 2.1: Number of Citations per Discipline Per Year 



Biomedical Research 

When the "crack scare" began in 1985, the majority of research on cocaine 
exposed newborns focused on the potential neurological and physiological damage 
caused by the drug using a teratogenic or deficit model approach. Health care providers, 
researchers, educators, and social servants developed a deep concern for prenatally 
cocaine exposed children as a consequence of these early reports of severe prenatal and 
postnatal problems caused by pregnant women's use of crack cocaine. As seen in media 
reports on the prevalence of the problem, many people also became anxious about the 
impact prenatally cocaine exposed children would have on our health and social service 



10 

systems (Archibald 1992; Bays 1990; Martinez 1995). These concerns resulted in a 
drastic increase in the number of research studies on the topic. However, many of these 
studies lacked either an inclusive theoretical perspective or a sound methodological 
framework (Zuckerman and Frank, 1994). 

Early biomedical studies reported problems such as spontaneous abortions 
(Cherukuri, Minkoff, Feldman, Parekh, and Glass 1988; Lutiger, Graham, Einarson, and 
Koren 1991; Ryan, Ehrlich, and Finnegan 1987; Wang and Schnoll 1987), premature 
births (Cherukuri et al. 1988; Rosenak, Diamant, Yaffe, and Homstein, 1990), low birth 
weight (Cherukuri et al. 1988; Chouteau, Namerow, and Leppert 1988; Ryan et al. 1987; 
Zuckerman et al. 1989), and irreversible birth defects (Chavez, Mulinare, and Cordero 
1989) in cocaine exposed human newborns. Yet, more recent studies have published 
contradictory evidence due to differences in their study design and use of different 
statistical controls. 

For example, both Cherukuri et al. (1988) and Chouteau et al. (1988) reported that 
cocaine use during pregnancy caused low birth weight among exposed infants, but they 
both did not find similar results when comparing the relationship between prenatal 
cocaine exposure and spontaneous abortions or premature births. In the Cherukuri et 
al.(1988) study, which did not control for the use of prenatal care, cocaine exposure was 
related to preterm births, whereas in the Chouteau et al. (1988) study, which controlled 
for prenatal care and a variety of social demographic factors, cocaine exposure was not 
related to pre-term births. According to Chouteau et al. (1988), lack of prenatal care was 
a significant predictor of this poor health outcome. 



11 

The following studies published in the late 1980s also failed to control for social 
and environmental factors that could substantially influence the study results. In 1989, 
Zuckerman and his associates reported the findings from a prospective study that 
included 1226 pregnant women and their newborn infants. In their study on the impact of 
cocaine exposure on fetal outcomes, the researchers found that when comparing the 
newborns of women who tested positive for cocaine (n=l 10) to non-cocaine users 
(n=l 1 16), the newborns of cocaine users had significantly lower birth weights (p = 0.07), 
a decrement in length (p = 0.01), and proportionally smaller head circumferences (p = 
0.01) than the non-exposed newborns (Zuckerman et al. 1989). Even though the number 
of the cocaine-exposed infants included in the study was considerably smaller than the 
non-cocaine exposed infants, the researchers were able to control for a variety of 
physiological factors in this study; yet, social and environmental factors that can 
influence neonatal outcomes were not controlled. 

Chavez, Mulinare, and Cordero (1989) conducted a retrospective study of 
congenital anomalies in children born in Atlanta area hospitals between 1968 and 1980. 
In this study, the researchers report a statistically significant relationship between 
maternal cocaine use and urinary tract anomalies in infants (crude odds ratio, 4.39; 95% 
confidence interval, 1.12 to 17.24). However, this study did not control for the social, 
demographic, or environmental factors that may also relate to poor birth outcomes, such 
as race, access to prenatal care or socioeconomic status. 

Kliegman and associates (1994) conducted a prospective study of the effect of 
prenatal cocaine exposure on birth weight and prematurity. In the Kliegman (1994) 
study, of the eleven sociodemographic and physiological variables analyzed, race and 



12 

utilization of prenatal care services, along with cocaine, marijuana, and cigarette use, 
were significantly con-elated with poor birth outcomes. Cocaine exposure (odds ratio, 
13.4; 95% confidence intervals, 1.23 to 145.0) and prenatal care (odds ratio, 9.89; 95% 
confidence intervals, 3.74 to 26.17) were significant predictors of low birth weight and 
premature births, demonstrating a need to assess the long-term effects of these variables 
on developmental outcomes. 

Most studies concur that prenatal cocaine exposure results in low birth weight and 
prematurity, but there are also other factors, like the lack of prenatal care, race, and 
overall maternal health, that are related to these poor health outcomes. In 1997, Lester 
and his associates constructed a database of studies on prenatal cocaine exposure (Lester, 
LaGasse, and Brunner 1997). The 76 studies included in the final database (1) pertained 
to cocaine use during pregnancy, (2) were based on original research using human 
subjects, (3) included neurobehavioral measures, (4) included control or comparison 
groups, (5) analyzed the data statistically, and (6) were found in peer reviewed or 
refereed publications. 

The analysis of the articles included in the database lead Lester and his colleagues 

to contend that the neurodevelopmental disorders identified in infants participating in the 

studies on prenatal cocaine exposure could be attributed only partially to the presumed 

neurological damage caused by drugs. Lester et al. (1997:487) writes: 

The data base shows that our knowledge base is limited, scattered, and 
compromised by methodological problems that mitigate any conclusions 
about whether or not or how prenatal cocaine exposure affects child 
outcome. Only a few studies have followed children beyond age 3. In 
addition, the cocaine problem is more complicated than first envisioned. 
It is a multifactorial problem including the use of other drugs and 
parenting and environmental lifestyle issues. 



13 

Lester and his colleagues (1996, 1997) along with other behavioral researchers 
(Graham and Koren 1991) have suggested that there are social, environmental, and other 
medical conditions that may contribute to the poor health outcomes of prenatally exposed 
children, but as indicated by my review of the literature and Lester's database, very little 
of the research conducted by natural scientists address social concerns. Of the articles I 
reviewed, none of the biomedical studies were initially designed to address the social and 
environmental concerns that many behavioral and social science researchers deem 
important. 
Behavioral (Psychological) Studies 

The psychological and behavioral research that addresses the social and 
environmental conditions affecting the development of prenatally exposed newborns has 
helped shift the focus from the biomedical to the social and environmental. Many of the 
psychologically oriented studies of prenatal cocaine exposure focus on how cocaine 
exposure influences the behavioral development of newborns and young children. This 
differs from the biomedical focus on the effects of cocaine on human physiology and 
subsequent health outcomes. The behavioral studies also tend to include more 
psychosocial controls, thus providing further explanation of the differences or lack of 
differences between children who have been prenatally exposed to cocaine and non- 
cocaine exposed children. 

For example, Woods and associates conducted a study of the effect of cocaine 
exposure and maternal affect on the neurobehavioral development of neonates (Woods, 
Eyler, Behnke, and Conlon 1993). This study included maternal depression and prenatal 
care as psychosocial controls. In this well-controlled and methodologically sound study, 
the researchers did not find any significant differences in the neurobehavioral 



14 

development of one-month old infants who were and who were not exposed to cocaine 
prenatally. This study from the larger research project from which I am drawing my data, 
employed a theoretical framework that acknowledged the importance of psychosocial 
factors, while using a sound quasi-experimental design. 

Many of the studies found under the behavioral or psychological rubric have 
employed similar experimental designs that are intended to control for physiological and 
environmental factors that may influence the results. Some of the researchers have 
acknowledged the influence that the social environment has on developmental outcomes 
(Bendersky and Lewis 1998; Grant, Bendersky, and Lewis 2000; Alessandri, Bendersky, 
and Lewis 1998), but there are still many studies that lack sound methodological 
guidelines making it difficult to present conclusive results. 

In a recent article by Singer (1999) titled "Advances and Redirections in 
Understanding Effects of Fetal Drug Exposure," the author calls for researchers to use 
more "rigor" in their methodological designs, to improve "quantifiable and self report 
measures," and to use more "sensitive" statistical models. These comments are a 
response to the inconclusiveness of the existing research on children who have been 
prenatally exposed to a variety of drugs, including cocaine. 

Many biological and behavioral researchers have been unable to conclusively 
state that cocaine use during pregnancy directly impacts later behavior in the pre-exposed 
child. The studies that have been published utilize longitudinal, cross-sectional, 
retrospective, prospective, and case controlled research designs and they vary in how 
prenatal cocaine use is measured, defined, and analyzed (Mayes, Granger, Bornstein, and 
Zuckerman 1992). The inconsistency in research methodologies makes it very difficult 



15 

to summarize the research findings pertaining to the effect of prenatal cocaine exposure 
on behavior and development from a biomedical or a behavioral perspective. Linda 
Mayes' (1996) review of the literature found that most studies dealing with behavioral 
and developmental problems among cocaine exposed children were plagued with 
methodological problems, such as poor population sampling, issues of polydrug use, lack 
of longitudinal data, and lack of environmental controls. 

For example, the variability in research designs has lead to contradictory results in 
several behavioral and developmental studies. In an article written by Angelilli and 
associates (1994), it is stated that children with a detected language delay are more likely 
to have been prenatally exposed to cocaine than children with normal language 
development. However, this finding is based on a study of language delay in which 29 
children with delays were compared to children with no delays and prenatal drug use was 
collected retrospectively from the child's caregiver during the child's clinical 
appointment. The researchers found prenatal cocaine and nicotine exposure to be 
significantly correlated with language delays among children aged 24 to 48 months. The 
research design does not allow for adequate controls nor does it verify the nature of the 
cocaine exposure. 

In a prospective longitudinal study of prenatal cocaine exposure with masked 
evaluators conducted by Hurt and her colleagues (1997), the researchers did not find any 
relationship between poor language development and prenatal cocaine exposure among 
their matched sample of prenatally cocaine and non-cocaine exposed subjects at 30 
months of age using the Preschool Language Scale. However, in a different study, 
Johnson and his peers (1997) found significant differences in language ability and 



16 

development skills between prenatally cocaine exposed and non-exposed children 
between 1 1 and 50 months using the Sequenced Inventory of Communicative 
Development-Revised and the Bayley Scales of Infant Development. This study included 
a matched sample of children who had been living in stable, drug free environments at 
the time of the testing. 

Eyler and Behnke (1999) created a comprehensive review of the literature on 
prenatal cocaine exposure's influence on early development. Like Mayes (1996), Eyler 
and Behnke also comment on the variability in methodologies that make it difficult to 
make conclusive statements about cocaine's influence on early childhood development. 
According to Eyler and Behnke (1999), approximately one third of the neonatal studies 
they reviewed found that prenatal cocaine exposure did not influence behavioral 
development. The most commonly reported findings were poorer state and autonomic 
regulation, irritability, and decreased alertness and orientation among cocaine exposed 
neonates. In studies of three to twenty-four month old infants, about half found no 
differences between prenatally cocaine exposed and non-exposed infants in development 
or adaptive behavior. According to Eyler and Behnke (1999), other studies found that 
prenatally cocaine exposed children experienced problems with arousal and 
responsiveness, visual expectancy, recognition memory, information processing, and 
attachment and play during the first year of life. 

Singer (1999) proposes more systematic questioning and longitudinal research as 
a means of determining the long-term effects of cocaine on behavior, while I propose 
different questions and more sociological research as a means of increasing our 






17 



understanding of the relationship between prenatal cocaine exposure and childhood 
outcomes. 

Sociological Studies 

In my review of the literature, I was able to identify only 20 studies on "prenatal 
cocaine exposure" and/or "cocaine and pregnancy" in the sociology databases. Only 
four of these articles pertained to prenatally cocaine exposed infants. The majority of the 
articles were about drug use among pregnant women (Bendersky, Alessandri, Gilbert, 
and Lewis 1996; Choe, Murphy, and Murphy 1998; Higgs 1996; Humphries 1998; 
Humphries, Dawson, Cronin, Keating, Wisniewski, and Eichfeld 1992; Kearney and 
Murphy 1993; Kearney, Murphy and Rosenbaum 1994; Lanehart, Clark, Kratochvil, 
Plings, and Fidora 1994; Maher 1990; Murphy and Ferreboeuf 1997; Pursley-Crotteau 
and Stern 1996; Singer, Arendt, Minnes, Farkas, Yamashita, and Kliegman 1995; Smith, 
Dent, Coles, and Falek 1992; Teagle and Brandis 1998). The articles that dealt with 
prenatally cocaine exposed infants addressed issues of care-giving (Franck 1996; Hamid 
1994), the protection of prenatally exposed infants (Besharov 1989), and the problems 
these children present to society (Best 1994). Unlike the biomedical and behavioral 
studies, these studies did not focus on the effect prenatal cocaine exposure has on the 
developing child, but rather the impact prenatally exposed children have on the world in 
which they live. 

There are numerous methodological and theoretical gaps within the sociological 
literature, given the limited number of articles and their limited scope. There are studies 
that address social issues, such as the relationship between prenatal cocaine exposure and 
the parenting, home, and community environments, but these were not found within the 
sociological databases used in this literature review, because these studies lacked a clear 



18 

sociological perspective. Therefore, my research is intended to fill the gap by conducting 
research on prenatal cocaine exposure from a viewpoint that is not only sociological, but 
multidimensional in nature as well. 

In any research that depends on the study of human subjects within their social 
environment, it is very difficult to maintain a strict disciplinary focus while conducting 
research that requires a rigorous experimental design. Human subjects are difficult to 
study because what happens in the course of the human subjects' life when outside of a 
laboratory is impossible to control. Unlike rats used in experimental research, it is nearly 
impossible and in virtually all cases unethical to place humans in a box or a controlled 
environment for a prolonged period of time to analyze their behavior while exposing 
them to a lethal substance, such as cocaine. Social science researchers can benefit from 
the methods used by behavioral scientists, and biomedical scientists can benefit from the 
social context incorporated into research studies by social scientists. Hence, a 
multidimensional integrative approach needs to be employed. 

Conclusion 

The study of the effect of prenatal cocaine exposure and the social environment 
on the behavior and development of children requires a research design that incorporates 
the methodological strengths found in experimental research and a theoretical framework 
that allows one to examine numerous levels of influence on an outcome. This is why I 
advocate the use of a conceptual model that integrates social, behavioral, and biomedical 
methodologies and theoretical perspectives. Despite the contributions biomedical, 
behavior, and social science researchers have made to the literature on the impact of 



19 

prenatal cocaine exposure on the developing fetus and infant, there is still a knowledge 
gap to fill. 

Since the mid-1980s, numerous biomedical studies 1 (Azuma and Chasnoff 1993; 
Bellini, Massocco, and Serra 2000; Chiriboga, Brust, Bateman, and Hauser 1999; Fantel 
and Macphail 1982; Garavan, Morgan, Mactutus, Levitsky, Booze, and Strupp 2000; 
Roland and Volpe 1989; Volpe 1992; Vorhees 1995; Zuckerman 1985), behavioral 
studies (Alessandri, Sullivan, Bendersky, and Lewis 1995; Eyler and Behnke 1999; 
Leech, Richardson, Goldschmidt, and Day 1999; Lester, Corwin, Sepkoski, Seifer, 
Peucker, McLaughlin, and Golub 1991; Richardson, Hamel, Goldschmidt, and Day 1996) 
and development studies (Arendt, Singer, Angelopoulos, Bass-Busdiecker, and Mascia 
1998; Coles and Platzman 1993) have reported on the negative effects of cocaine on fetal, 
neurological, physiological, cognitive, and behavioral outcomes. However, with the 
exception of a few recent studies and reviews (Hubbard 1998; Inciardi, Surratt, and Saum 
1997; Mayes 1992; Smith 1992), very little sociological or multidisciplinary research has 
been done on children who have been prenatally exposed to cocaine. Incorporating a 
multidisciplinary perspective will help further our empirical understanding of the social, 
structural, environmental, and psychosocial factors that shape children's development 
and that influences their behavior. 



1 The included references exemplify studies published and cited repeatedly over the past 
twenty years. In no way is it an exhaustive list of all the research produced on prenatal 
cocaine exposure. 



CHAPTER 2 
MULTIDIMENSIONAL MODEL 



The plethora of contradictory and inconclusive findings in the biomedical and 
behavioral science literature on the effects of prenatal cocaine exposure is demonstrative 
of how the existing knowledge gaps are best filled by a multidimensional approach. In 
this study, I apply a multidimensional approach that integrates biomedical, behavioral 
and sociological principles. This theoretical process is consistent with the vision of the 
new social and behavioral health science research taking place at the national level 
(Singer & Ryff 2001). The multidimensional model that I have conceptualized is heavily 
influenced by the research agenda established by the Office of Behavioral and Social 
Science Research (OBSSR) at the National Institutes of Health (NIH). The OBSSR 
agenda prioritizes the study of "biological, behavioral, psychological, and social 
precursors to disease" and "biological, behavioral, and psychosocial factors that 
contribute to resilience, disease, resistance, and wellness" (Singer and Ryff 2001: 3). 

In this chapter, I outline the multidimensional model and how it will be applied to 
the study of the behavior and development of prenatally cocaine exposed children. I 
begin by providing a brief background of the sociological perspective, in order to provide 
a foundation for the multidimensional model that bridges the gap between the social, 
behavioral, and biomedical disciplines. Then I proceed by defining behavior and 



20 



21 

development and the rationale for studying pre-school aged children. The chapter ends 
with a restatement of the research questions and general hypotheses. 

Sociological Perspective 

From a sociological perspective, the study of behavior and development typically 
involves the study of human interaction and the relationships that evolve from that 
interaction. These relationships are manifested in the form of social roles, norms and 
groups that dictate human behavior and can influence human development. In sociology, 
behavior is more or less viewed in terms of social action or performance and 
development is seen within the context of the life course. Micro-sociological theories, 
such as symbolic interaction, focus on the factors that drive social performance or action 
(Berger & Luckmann 1966), while macro-sociological theories, like the life course 
perspective, focus on how larger social forces or period events impact society over time 
(Elder 1995). 

This study incorporates both micro and macro level concepts. These concepts 
facilitate our understanding of how micro level constructs (such as maternal drug use 
and/or parent-child interaction) interact with macro constructs (like social and economic 
demographics) to predict outcomes for children whose lives have been effected by the 
physiological and social consequences of prenatal cocaine exposure. The use of multiple 
dimensions to create a more complex understanding of social life and social structures is 
the foundation of sociology as a discipline (Parsons 1951). Sociology is not simply the 
study of society, but the study of relationships between multiple dimensions of society, 
including biomedical, behavioral, and social factors. 






22 

Talcott Parsons (1982), a leader in the field argues that sociology should be driven 
by analytical theories that: 

• help the researcher determine which factors are important and which ones are not 
important to the research; 

• provide a basis for organization of the factors included in the analysis; 

• help uncover the existing knowledge gaps that need to be filled; and 

• allow for the integration of theories from related disciplines. 

The multidimensional approach that drives this research attempts to do these four 
things by examining the existing research and integrating theory. The review of the 
literature on prenatal cocaine exposure helped me to identify what factors should be 
included in the multidimensional model and how they should be organized. Plus, the 
literature review allowed me to uncover the existing knowledge gaps, in particular the 
lack of an integrative approach and the need for more research on pre-school aged 
children's behavior and development. Therefore, my research integrates micro and 
macro level constructs from a variety of disciplines as a means of constructing a 
multidimensional model of the behavior and development of prenatally cocaine exposed 
children. 

Components of the Multidimensional Model 

I have constructed a multidimensional model of behavior and development that 
integrates the biomedical, behavioral, and social sciences. As exhibited in the previous 
chapter, the research conducted by biomedical, behavioral and some sociological 
researchers present contradictory results on the effects of prenatal cocaine exposure on 
the developing child. There is some evidence that prenatal cocaine exposure is 
significantly correlated with fetal brain disruption (Bellini 2000), low birth weight 
(Cherukuri et al. 1988; Chouteau et al. 1988; Ryan et al. 1987; Zuckerman et al.1989) 






23 

and premature births (Cherukuri et al. 1988). Several behavioral research studies have 
revealed that prenatal cocaine exposure is related to poor motor development (Arendt, 
Angelopoulos, Salvartor, and Singer 1999), cognitive development (Alessandri et 
al.1998; Arendt et al 1998), and language development (Angelilli, Fischer, Delaney- 
Black, Rubinstein, Ager, and Sokol 1994; Johnson, Seikel, Madison, Foose, & Rinard 
1997), yet the sociological literature (or lack there of) reminds us that there are still a lot 
of unanswered questions about the relationship between the prenatal and postnatal 
influences on developmental and behavioral outcomes for these "at-risk" children. 

I intend to employ a sociological perspective to examine not only how prenatal 
cocaine exposure relates to two particular outcomes, but I will examine how prenatal 
cocaine exposure impacts these outcomes when it is included in a conceptual model that 
includes neonatal and postnatal factors. The conceptual model of behavior and 
development presupposes that prenatal and neonatal physiological factors and postnatal 
behavioral and social environmental factors each play a role in determining the behavior 
and development of prenatally cocaine exposed children as they age. This 
multidimensional approach provides a consummate strategy for studying such a complex 
problem. 

The multidimensional model I have created combines the tenets of sociology, 
ecology, psychology, and biomedicine by defining social action, the sociological concept, 
as the biological mother's use of cocaine during pregnancy and by using biomedical, 
behavioral, and sociological constructs to describe the biomedical and social ecological 
factors included in the model. The prenatal and neonatal dimensions represent the 
biomedical factors and the social ecological factors represent the postnatal dimension. 



24 

The neonatal and postnatal factors help mediate the effect of the prenatal dimension on 
behavior and development, two psychologically oriented constructs. 

Prenatal Dimension 

First, the negative effect of cocaine could be a result of the physiological impact 
cocaine has on the developing fetus or it could be due to the fact that many children born 
to cocaine using mothers are at a greater risk of reaping the negative social consequences 
of their mother's cocaine habit. These consequences include biomedical and sociological 
risk such as, lack of proper health care and nutrition, exposure to numerous drugs during 
and post pregnancy, the risk for physical and emotional abuse, poverty, high residential 
mobility, and poor or limited parent child interaction due to incarceration, limited 
sobriety, or the termination of parental rights because of the mother's drug use. 
Therefore, regardless of whether or not prenatal cocaine exposure has a physiological or 
sociological effect on children, it is a significant predictor in the multidimensional model 
of behavior and development. 
Neonatal Dimension 

The second factor included in the model is the measure of the neonatal 
environment. The neonatal environment is characterized by the child's health status at 
birth. According to the biomedical model, the complications encountered during 
pregnancy and during labor and delivery are indicative of a child's risk for future health 
related problems (Hobel, Youkeles, & Forsythe 1979); therefore, it is an important 
variable in the multidimensional model of adaptive behavior and development. Simply 
evaluating the relationship between the neonatal environment (prenatal cocaine exposure) 
and behavior and development, negates the role that neonatal risk factors and postnatal 
social factors play in determining a child's outcomes. 






25 

Postnatal Dimension 

The social environment, which characterizes the postnatal environment is the 
third dimension in the multidimensional model. The potential social influences on 
behavior and development are numerous. Bronfenbrenner's social ecological model 
serves to organize the most salient factors, including the caregiver, home, family, and 
social structural variables. Each of these variables represent what Bronfenbrenner calls 
the micro-, meso-, exo-, and macrosystems in his ecological model of human 
development (Bronfenbrenner 1979). 

Theoretical Framework 
Social Ecological Theory 

Bronfenbrenner's (1979) ecological model of human development provides a 

foundation for describing the relationship between multiple factors and their influence on 

an outcome. Using the principles of systems theory, Bronfenbrenner's (1979) ecological 

approach describes how a series of environmental systems create dimensions of influence 

on human development and ultimately behavior. In his book, The Ecology of Human 

Development, Bronfenbrenner defines the ecology of human development as such: 

The ecology of human development involves the scientific study of the 
progressive, mutual accommodation between an active, growing human 
being and the changing properties of the immediate settings in which the 
developing person lives . . . (Bronfenbrenner 1979: 21). 

In other words, ecology is the study of humans and their relationship to the environment 

in which they live. The definition offered by Bronfenbrenner reminds social scientists 

that the relationship that is being observed is not static, but dynamic and it is subject to 

change as human and environmental properties change. 



26 

Bronfenbrenner goes on to state: "... this process is affected by relations 
between settings, and by the larger contexts in which the settings are embedded" 
(Bronfenbrenner 1979: 21). He describes the observed relationship between humans and 
their environment as a system that is embedded within other systems similar to a set of 
Russian dolls. The smallest doll represents the most immediate setting or the 
microsystem. The microsystem is encompassed by the mesosystem proceeded by the 
exosystem. Last, the entire system is influenced individually and collectively by the 
macrosystem reflecting a higher level of influence, such as culture or subculture 
(Bronfenbrenner 1979). 

The microsystem has been defined as the psychosocial status of the child's 
primary caregiver. According to child development theorists, there is a direct 
relationship between parental attitudes and behaviors and children's outcomes (Cochran 
and Brassard 1979). Additionally, Zuckerman and his associates (1990) found a 
significant relationship between early childhood problems and maternal depression even 
when controlling for cocaine exposure status. Bronfenbrenner (1979) refers to this 
relationship between parents and their children as a dyadic relationship that functions in a 
reciprocal fashion. 

For instance, a mother who experiences depression may be less responsive to her 
child's needs resulting in poor behavioral outcomes for the child. Reciprocally, a child 
who presents numerous behavioral and developmental problems may contribute to 
increased feelings of helplessness and depression for the mother. Researchers have found 
that maternal depression is related to poor child rearing practices (Coletta 1983) and that 
poor parental efficacy is correlated with poor behavioral outcomes for children (Johnston 



27 

and Mash 1989). Hence, the psychosocial status of the primary caregiver is included in 
the postnatal factor of the multidimensional model as a means of assessing its 
relationship to behavior and development. 

The mesosystem is defined as the nature and quality of the child's home 
environment. Like the microsystem, the mesosystem is presumed to influence behavior 
and development. Studies on the home environment have shown that children who live 
in stimulating and loving environments can overcome numerous obstacles, such as 
developmental delays caused by poor neonatal health outcomes (Mayes 1996), foster care 
placement (Horwitz, Simms, and Farrington 1994), parental divorce, and poverty (Miller 
& Davis 1997). According to Bronfenbrenner (1979), children's developmental potential 
is enhanced when their physical and social environment enables them to participate in a 
variety of activities. 

The family's social support mechanism reflects the exosystem and the families' 

sociodemographic characteristics comprise the macrosystem in the postnatal 

environmental factor. Bronfenbrenner' s ecological model of human development clearly 

states that the relationship between the family and its support mechanisms and the 

family's access to support mechanisms is a critical part of human development; hence 

these are essential parts of the multidimensional model that has been constructed to 

evaluate the behavior and development of the children in this study. According to 

Bronfenbrenner (1979: 7): 

. . .whether parents can perform effectively in their child-rearing roles 
within the family depends on role demands, stresses, and supports 
emanating from other settings. As we shall see, parents' evaluations of 
their own capacity to function, as well as their view of their child, are 
related to such external factors such as flexibility of job schedules, 
adequacy of child care arrangements, the presence of friends and 



28 

neighbors who can help in large and small emergencies, the quality of 
health and social services, and neighborhood safety. 

The factors that characterize the exosystem and the macrosystem are related to 
parental behavior, which in turn is related to childhood behavioral and developmental 
outcomes. Parents who have a greater sense of family and social support will experience 
less stress, thus enhancing their relationship with their children. The improved 
relationship between parent and child leads to improved behavioral development 
(Cochran and Brassard 1979; Dunst and Trivette 1986; Johnston and Mash 1989). 

Additionally, the social and economic factors that characterize the macrosystem 
serve as proxies for the availability of flexible job schedules, the quality of care, and the 
relative safety of the neighborhood. These factors in the postnatal environment also have 
an effect on parental behavior; thus having an impact on childhood outcomes. Families 
who have limited economic resources are more likely to have less flexible jobs, poorer 
quality health care, and to live in economically disadvantaged neighborhoods plagued by 
crime and other safety hazards. 

The prenatal, neonatal and postnatal dimensions of the multidimensional model 
were determined by integrating biomedical, behavioral, and sociological theories, as 
encouraged by Talcott Parson's (1982), who called for sociologists to integrate theories 
from a multitude of disciplines. He also argued that sociology should be driven by 
analytical theories that provide a basis for how the factors in a model are organized. I 
have organized the multidimensional model using the compensatory model of resilience 
introduced by Zimmerman and Arunkumar (1994). The prenatal environment represents 
the biomedical risk to early childhood outcomes while the neonatal and postnatal 
biomedical, behavioral, and sociological factors compensate for the impact of the 



29 

prenatal risk. It is presumed that the positive attributes found in the neonatal and 
postnatal environments will contribute to the resiliency of "at-risk" children. 

Resiliency Theory 

Resiliency theory is useful in understanding individual development and behavior 
(O'Connor and Rutter 1996; Rutter 1989). According to resiliency theorists, there are 
two central theorems that illustrate the concept of resilience, the compensatory and the 
protective models (see Figure 3.2). Traditionally, resiliency is defined as the ability to 
recover after experiencing some type of distress or misfortune. This distress is referred to 
as a risk factor in resiliency models. Resiliency researchers strive to identify the factors 
that either compensate for the distress (compensatory model) or that protect individuals 
from the distress (protective model) resulting in positive outcomes (Davis 1999; 
Zimmerman and Arunkumar 1994). 



Compensatory 


Model 










OUTCOME 


RISK 

FACTOR 


h 


w 
















COMPENSATORY 
FACTOR 


/ 











Protective Model 













RISK 
FACTOR 




OUTCOME 


i 


k w 
















PROTECTIVE 
FACTOR 





Source: Zimmerman and Arunkumar (1994) 



Figure 3.1: Compensatory and Protective Models of Resilience 



According to the compensatory model, the compensatory factor mediates the effects of 
the risk factor by providing additional support or strength. Both factors directly influence 



30 

the outcome. This differs from the protective model, in that the risk and the protective 
factors interact with one another to influence the outcome. In the protective model, the 
protective factor intervenes by reducing or eliminating the risk factor. 

In this study, I hypothesize that the observed outcomes, behavior and 
development, are directly influenced by two compensatory factors, neonatal risk and the 
postnatal social ecological system. In the multidimensional model, I propose that 
prenatal cocaine exposure is directly related to the behavior and development of pre- 
school aged children, but I also propose that it is not the only factor that has an impact on 
the outcome. 

As shown in Figure 3.2, the compensatory factors play a significant role as well. 
I contend that the compensatory factors are directly related to behavior and development. 
This theory is driven by my belief that the neonatal and postnatal environments do not 
intervene as the protective model presumes, but these biomedical and sociological 
factors, actually compensate for the prenatal risk in an additive fashion. Prenatal cocaine 
exposure, neonatal health status, and the postnatal social ecological factors each play a 
part in determining the behavior and development of pre-school aged children. 
Therefore, prenatally cocaine exposed children may be able to overcome the risk 
associated with prenatal cocaine exposure when the neonatal risk is reduced and the 
postnatal environment is optimized. 



31 



Neonatal 

Health Risk 
Dimension 



Prenatal Risk 
Cocaine Exposure 



Behavior and 
Development 



Postnatal 

"Social Ecological'' 

Dimension 



Red = Risk Factor; Green = Compensatory Factor; Blue= Outcome 



Figure 3. 2: Multidimensional Model of Behavior and Development 



Definitions Of Behavior And Development 

Behavior and development can refer to many different constructs and both terms 
have been defined and measured in different ways. In this research, I define and measure 
behavior and development separately. The term behavior actually refers to the children's 
adaptive behavior or their ability to demonstrate the skills and perform the tasks that are 
expected of them as they reach maturity. Behavior reflects the acquisition of the 
necessary skills for taking care of oneself and getting along with others (Vineland 1984). 
The study of adaptive behavior among prenatally cocaine exposed children is important 
because it serves as a proxy for the child's ability to survive in a complex world that 
requires independence, as well as social cooperation or the ability to conform to social 



norms. 



32 

Development refers to the achievement of particular growth parameters in 
relation to chronological age. The typical measures of development include abstract 
reasoning, memory, learning, and problem-solving abilities and fine and gross motor skill 
development. These skills play an important role in a child's ability to orient towards the 
environment and they influence the quality of the child's interaction with the 
environment (Bayley 1969). In this study, development and behavior are measured 
independently, but they are presumed to follow the same pathways. Some developmental 
scientists would argue that the behavior and development are inextricably intertwined 
(see Bergman, Cairns, Nilsson, & Nystedt 2000; Bijou and Ribes 1996; Immelmann, 
Barlow, Pterinovich, & Main 1981; Pujol, Vendrell, Junque, Marti-Vilalta, & Capdevila 
1993 for discussions on behavior development); hence, the application of one model for 
both constructs. 
Reason for Studying Pre-Schoolers 

Half of the children included in this study of adaptive behavior and development 
have been prenatally exposed to cocaine and the other half have not been exposed to 
cocaine prenatally, but both groups can be defined as "at risk" of poor behavioral and 
developmental outcomes. The majority of the sample is comprised of Black children 
born of relatively inexperienced and poorly educated mothers. By age three, many of the 
children are living with primary caregivers who are at-risk of depression and who have 
household incomes below the poverty line. 

Thirty-six months is a prime age to observe the behavior and development of 
these "at-risk" children, because as children reach the age of three, they are expected to 
perform tasks and acquire skills that are not easily measured or observed during earlier 
ages. According to the American Academy of Pediatrics, three-year old children are 



33 

increasingly social and inquisitive, thus enhancing their independence, which is marked 
by their attempts at communication and mobility (Cowley 2000; Kantrowitz 2000; 
Raymond 2000). The acquisition of social, communication, daily living, mental and 
motor skills are important to the child's overall growth and development; however for 
many poor, Black children their growth and development is thwarted by their 
impoverished social and economic status (Brooks-Gunn & Duncan, 1997; McLeod & 
Nonnemaker, 2000; McLoyd, 1990). 

Studying behavior and development at age three makes methodological sense 
because, most children have not entered a formal educational institution; therefore, the 
influences on their behavior and development are considerably less than school age 
children. Even though three-years is a relatively short period of time given the typical 
age of mortality in the United States, three-year olds do have a life course trajectory. 
According to the multidimensional model, their prenatal, neonatal, and postnatal 
environments reflect a trajectory that impacts their behavior and their development as 
they mature. Each environmental dimension represents a particular level of influence in 
the multidimensional model. The neonatal and postnatal environments represent levels of 
influence that compensate for the risk associated with a harmful prenatal event, 
specifically prenatal drug exposure. 

Research Questions 

The conceptual model outlined in this chapter will be used to answer the 

following questions: 

How do prenatally and non-prenatally cocaine exposed children differ on 
measures of behavior and development at age three? 



34 

To what extent do prenatal, neonatal and postnatal factors, including 
prenatal cocaine exposure, neonatal health and the postnatal social 
ecological factors, enhance or hinder pre-school age children's behavior 
and development? 

I expect that when controlling for the neonatal and postnatal factors, the 
impact of prenatal cocaine exposure on the behavior and development of pre- 
school aged children will be reduced. Previous researchers have found significant 
differences between prenatally and non-prenatally cocaine exposed infants, 
whereas the exposed infants are at a greater risk of experiencing poor outcomes. 
But does the effect of prenatal cocaine exposure persist beyond infancy and into 
early childhood? And if so, can these effects be compensated for when the child 
has minimal health problems and resides within a positive social ecological 
setting? The anticipated answers to these questions are outlined in the next 
chapter, which also includes a detailed description of the research methods, the 
hypotheses and how they are operationalized. 



CHAPTER 3 
RESEARCH VARIABLES AND SAMPLE DESCRIPTION 



Designing a quality study involves constructing a research protocol that contains 
valid and reliable measures of the variables outlined in the theoretical model. This helps 
to minimize the bias that results from poorly designed studies. After creating the 
conceptual framework outlined in the previous chapter, I was fortunate enough to find a 
source of data that contained the variables necessary to address the questions posed in the 
previous chapter. In addition to the data source being comprehensive, the procedures 
used to collect the data are empirically reliable and valid to the extent that researchers are 
able to depend on the honesty and integrity of human subjects. In this chapter, I describe 
the data collection techniques, the longitudinal sample, and the operationalization of the 
prenatal, neonatal, and postnatal factors in the multidimensional model. 

Data Collection 

The data used in this study comes from a cross-section of the data collected for a 
longitudinal study on cocaine use among pregnant women conducted in the Department 
of Pediatrics at a university hospital in the southeastern region of the United States. From 
1991 to 2001, data were collected from study participants during their pregnancy, at the 
birth of the target child, and during scheduled follow-ups with the target child and his or 
her respective primary caregiver. The data used in this study come from the follow up 
interviews and assessments conducted when the target child reached 3 years of age. 



35 



36 

This study uses a quasi-experimental design to assess the adaptive behavior and 
development of children who have been prenatally exposed to cocaine by comparing 
them to a group of matched controls. The recruitment procedures were based on a 
matched group design in order to minimize the effects of possible confounding variables, 
such as socioeconomic status, race, parity, and level of prenatal risk (Behnke, Eyler, 
Woods, Wobie, and Conlon 1997). 

Recruitment took place between 1991 and 1993 at the recruitment hospital or at 
one of its surrounding prenatal clinics. The researchers approached a total of 2,526 
potential participants during their first or subsequent prenatal visit or at delivery in order 
to include a full range of pregnant cocaine users. Only women less than eighteen years of 
age, who did not speak English, who used an illicit drug other than cocaine and marijuana 
and/or confounding prescription medications, and those who were diagnosed with a non- 
drug related chronic illness known to effect pregnancy outcomes were excluded (e.g. 
diabetes, sickle cell). Of the 2,526 women recruited, 85% (n~2147) consented to 
participate in the study upon first approach. Upon consent, each woman was given a 
urine drug screen and a drug history interview. 

A power analysis was conducted to determine the necessary sample size in order 
to maintain statistical power of p = 0.05 and to detect an effect size within one-third of a 
standard deviation on developmental outcomes (i.e. the Bayley Scales for Infant 
Development). Based on the results of the power analysis it was determined that an 
enrollment of 150 cocaine users and 150 matched controls would be sufficient assuming 
an attrition rate of 33% over three years (Eyler, Behnke, Conlon, Woods, and Wobie 
1998). Hence, the first 179 women with positive drug screens and/or admitted cocaine 






37 

use at the time of delivery were asked to continue their participation in the study. Of 
these women 154 consented, fit the inclusion criteria and were positively identified as 
prenatal cocaine users based on their positive urine drug screen given on the day of 
enrollment and at delivery. One hundred and fifty-four women with negative drug 
screens and no admission of drug use were enrolled in the control group using the 
matching criteria. 

Urine specimens for the mother and infant were tested using fluorescence 
polarization immunoassay. Positive screens were confirmed through the use of gas 
chromatography-mass spectroscopy. This process involves the use of a magnetic device 
and computer technology to isolate the ionic components of the substance being tested. 
The use of two drug screens and detailed drug histories were employed to minimize the 
chances of misclassification of drug users as non-drug users (Behnke, Eyler, Woods, 
Wobie, and Conlon 1997). These methods of classification are highly regarded by 
researchers in the field (Arendt, Singer, Minnes, and Salvator 1999). The University's 
Institutional Review Board approved all methods and procedures and great care was 
taken to assure that each participant understood what she was agreeing to when signing 
the informed consent and to protect the confidentiality of all participants. 

Description of Longitudinal Sample and Sample Retention 
Description Of Birth Mothers 

At birth the total sample included 154 cocaine users and 154 non-cocaine users. 
Each woman was interviewed prior to the birth of the target child and/or immediately 
after the child was bom. When possible each woman was first interviewed during her 
initial entry into the health care system and during each subsequent trimester to facilitate 



38 

her recent recollection of drug use and other life events. Forty-one percent began their 
interviews during the first trimester, 34% during the second trimester and 25% of the 
women did not receive their first interview until delivery as a result of when the subject 
entered the health care system. The women enrolled at delivery received limited or no 
prenatal care. Women who were trained to establish rapport conducted the prenatal 
interviews. The interviewers were instructed to appear non-judgmental, supportive, and 
encouraging. This enhanced the reliability of the information collected. 

The group of cocaine users is not significantly different from the non-cocaine 
users on any of the matching criteria. The two groups were matched on race, 
socioeconomic status, parity, and perinatal risks. On average, the cocaine users were 
older than the non-users by 3 to 4 years, yet both groups fell within the same age range of 
18-43 with only two women (one in each group) over the age of 40 years. The majority 
of the cocaine users were Black (n=125). The majority of the cocaine users were 
classified as unskilled laborers as determined by the Hollingshead Index (Hollingshead 
1975) and the majority had received 12 years or less of formal education. The cocaine 
users and non-cocaine users reported some alcohol, marijuana, and tobacco use with the 
cocaine users reporting significantly higher usage rates on all substances. Forty-two 
percent of the sample reported never being married. Additionally, 134 of the cocaine 
users reported having previous births; hence they were matched with multiparous non- 
cocaine users. Table 4.1 provides a description of the biological mothers. Non- 
parametric statistical procedures were used to calculate the mean differences between the 
two groups. Each table reports the mean differences, the mean rank, and the Mann- 
Whitney p-value. 



39 



Table 4. 1 : Descriptive Statistics of Biological Mother and Child at Birth by Cocaine 
Exposure Status, Means +/- Standard Deviations (Mean Rank) 





Non- 


Cocaine 


Total 


Mann- 




Cocaine 
Exposed 


Exposed 


Sample 


Whitney 
Test 




n=154 


n=154 


N=308 


p-values 


Age in Years 


23.8 +/- 5.5 


27.6 +/-4.8 


25.8 


<0.001 


Years of Education 


11.4+/-1.1 


11.2+/-1.5 


11.3+/- 1.29 


0.440 


Completed 


(157.72) 


(150.25) 






Race = Black 


0.81 
(154.50) 


0.81 
(154.50) 


0.81+/-0.39 


1.000 


Symptoms of 


23.5 


29.7 


26.6 


<0.001 


Depression (CES-D) 










Socioeconomic 










Status 










Professional (1) 
Mid-level Prof (2) 
Skilled Worker (3) 
Semi-skilled (4) 
Unskilled (5) 




1 (0.7%) 

3(2.1%) 

29(20.1%) 

111(77.1%) 




1 (0.7%) 

3(2.1%) 

31 (21.5%) 

109 (75.7%) 




2 (0.6%) 

6(1.9%) 

60 (19.5%) 

220(71.4%) 


0.994 a 


Missing values 


10 


10 


20 (6.5%) 






a Chi 


-Square Test 







Characteristics Of Children At Birth 

Within the longitudinal sample of 308, there were several differences between the 
prenatally cocaine exposed and non-exposed children's birth outcomes. There were three 
fetal deaths among the women who used cocaine in utero and one death in the control 
group; however, the difference was not statistically significant (p = 0.62). As shown in 
Table 4.2, the women who used cocaine in utero were twice as likely to have a premature 
birth. 












40 



Table 4. 2: Longitudinal Study Sample Birth Outcomes by Cocaine Exposure Status, 



Means +/- Standard Deviations (IV 


ean Rank) 








Non-Cocaine 
Exposed 


Cocaine 
Exposed 


Total 
Sample 


Mann- 
Whitney 

Test 
p-values 


Infant's 
Gender = 
Female 


n=154 

0.45 
(146.29) 


n=154 

0.55 
(161.76) 


N=308 
0.47+/-0.50 


0.077 


Premature 
Infant = Yes 


n=154 

.09 

(114.83) 


n=154 

.19 
(120.26) 


N=308 
.14+/-0.35 


0.014 


Infant's Birth 
Weight 


n=153 

3179.4+/-699.6 
(166.1) 


N=149 

2984.9+/-668.2 
(136.5) 


n=302° 

3083.4+/- 
690.0 


0.003 


Hobel Risk 
Score 

Prenatal 

Labor & 
Delivery 

Neonatal 


n=151 

43.0+/-19.3 
(124.47) 

18.9 +/17.2 

(148.63) 

16.6 +/-36.2 
(142.64) 


N=148 

54.9 +/-20.6 
(176.04) 

18.1 +/14.1 
(151.40) 

21.6 +/-6 1.5 
(157.51) 


n=299° 
48.9+/-20.8 

18.6+/-15.7 

19.1 +/-50.3 


<0.001 
0.780 
0.135 


The missing values are attributed to fetal death and missed assessments for 
children born outside of the hospital. 



Nineteen percent (n=29) of the prenatally cocaine exposed neonates were born 
prematurely compared to 9% (n=14) of the non-prenatally cocaine exposed neonates. 
This difference is statistically significant at p=0.014. 

Also, there is a statistically significant difference between the prenatally cocaine 
exposed children and non-prenatally cocaine exposed children's mean birth weight (p = 
0.003). On average the birth weight of the PCE children is lower (mean = 2984 grams; 
standard deviation = 668) than the non-PCE (mean = 3179 grams; standard deviation = 



41 

670). Newborns who weigh less than 2500 grams at birth are considered low birth 
weight, placing them at risk for physical and developmental complications and even 
death. Twenty-two percent (n=33) of the PCE children weighed less than 2500 grams at 
birth compared to 11.8% (n=18) of the non-PCE children. As shown in Figure 4.1, the 
percentage of low birth weight babies in this sample is considerably higher than the 1994 
national average of 7.3%, 13.0% for Blacks, and 6.2% for whites (Ventura 1994). 



ioo.oo%| T 

80.00%- -T 
60.00% -T 
40.00% A 
20.00% A 
0.00%-U 




□ Non-PCE 
■ PCE 

□ Total 



JZ 







Above 2500 



Below 2500 



Figure 4. 1: Percent of Low Birth Weight Children by Prenatal Cocaine Exposure Status, 
n=302 



Even though there were differences in the average birth weight of the PCE 
children and non-PCE children, their Hobel Perinatal Risk Assessment scores did not 
differ considerably. Medical professionals assessed the risk of complications prenatally, 
during labor and delivery, and postnatally using the Hobel scoring system (Hobel 1973; 
Hobel 1979). The cocaine-exposed infants (mean=54.5; standard dev. =20.1) had 
significantly higher prenatal risk scores than the controls (mean =43.0; standard dev. 



42 

19.3), but there was no statistically significant difference on the labor and delivery (p = 

0.780) or neonatal scores (p = 0.135). 

Retention And Attrition At Three Year Follow Up 

During the three-year follow up, the researchers collected data from each primary 
caregiver of the child during a home interview and from each child during a clinic 
appointment. The home interviews that were conducted with each primary caregiver 
included measures of the caregivers' psychosocial status (CES-D), the home environment 
(HOME), the families' social support system (FSS), and the children's adaptive behavior 
(Vineland). A trained interviewer conducted the home interviews. Also, a blinded 
clinician on or around the child's third birthday completed the child's developmental 
assessment (Bayley). 

Of the initial 308 subjects, 80.2% (n=247) received both a home and a clinical 
assessment at age three. Ten of the children had died by age three and 14 families were 
lost to follow up or declined. Nine subjects completed either the home interview or the 
clinical assessment, but not both, and 39 missed some part of either the home interview 
or the clinic. As shown in Table 4.3, there is no significant difference between cocaine- 
exposed and non-cocaine-exposed groups in terms of their participation or lack of 
participation in the three year follow up (chi-square = 3.869 [4]; p=0.424). Additional 
analysis was done to compare the birth outcomes of the children who remained in the 
study to those who did not remain. There were no statistically significant differences 
between the initial sample's mean birth weight, Hobel complications assessment scores, 
gender, or prematurity status. Therefore, the 234 subjects with complete data are 
included in each bivariate and multivariate analysis with minimal risk of attrition bias. 



43 



Table 4. 3: Subject Retention and Attrition at 3-Year Follow Up 




Participation in Study at 
3 year Follow Up 


Control 
n=144 


Target 
n=138 


Total 

n=282 


Completed Both 


123 
39.9% 


124 
40.3% 


247 
80.2% 


Missed Clinic or Interview 


6 
1.9% 


3 
1.0% 


9 

2.9% 


Incomplete Clinic or 
Interview 


15 

4.9% 


11 

3.6% 


26 

8.4% 


Reasons for Exclusion 
from 3 year Follow Up 


Control 
n=10 


Target 
n=16 


Total 
n=26 


Child Died Prior to 3 year 
Follow-up 


5 
1.6% 


5 
1.6% 


10 
3.2% 


Unable to Locate for 

Follow-up 


5 
1.6% 


11 

3.6% 


16 

5.2% 


Total 


154 
50.0% 


154 
50.0% 


308 
100.0% 


Pearson Chi-Square=3.869 (d1 


F=4) alpha=0.424 



Operationalization Of Variables and Hypotheses 
Prenatal Risk: Prenatal Cocaine Exposure (PCE) 

Prenatal cocaine exposure was determined by multiple measures including 
maternal drug histories and urine assays taken from the mother during pregnancy and 
from the child at birth. Positive urine screens were confirmed using the gas 
chromatography -mass spectroscopy process. Target subjects included any woman who 
admitted to using cocaine and all the women and children who had positive confirmed 
urine screens for cocaine. Those who denied use and had negative cocaine screens 
comprised the control group. 

As in many of the studies of prenatal cocaine exposure, polydrug use exists 
among our sample of cocaine users. Both the cocaine users and some of the non-cocaine 
users reported the use of alcohol, marijuana, and tobacco. Subjects who reported the use 
of any illicit substance other than cocaine and marijuana were excluded from the study. 






44 

The amount of cocaine used by the cocaine users was determined from oral reports taken 
by the interviewer. Each cocaine user was asked how often they used cocaine, how much 
cocaine they used, or approximately how much money they spent on cocaine. The 
women in this study were primarily crack cocaine smokers. Their cocaine use ranged 
from smoking during as little as 2% of the time they were pregnant to as high as 100% of 
the time. On average, the cocaine users smoked crack during approximately 48% of their 
pregnancies (standard deviation = 0.28). Figure 4.2 is a histogram of the percent of 
weeks cocaine was used during the pregnancy for the cocaine users in the sample. Table 
4.4 shows the comparisons between the cocaine and non-cocaine users drug habits 
including the cocaine use for the initial longitudinal sample. 

The prenatal risk factor describes the children who were and who were not 
exposed to cocaine prenatally. All of the children of mothers who used cocaine during 
their pregnancy, regardless of the amount or timing of the use, were included in target or 
PCE group. This study is not a study of the variable effect of prenatal cocaine exposure, 
but a study of the differences between children who have been deemed "at-risk" due to 
prenatal cocaine exposure. Typically, the "at-risk" label is used without knowledge of 
maternal drug use during pregnancy, let alone the amount of cocaine used. Therefore, it 
in this particular analysis it is more appropriate to study the children who are "at-risk" of 
being labeled as "at-risk" than it is to study only the children with the greatest exposure 
to cocaine. 






45 



Histogram 









For TARGET^ target 



20 * 




£ o 



Stcl. Dev = .28 
Mean = .48 
N = 115.00 



0.00 .13 .25 .38 .50 .63 .75 .88 1.00 
.06 .19 .31 .44 .56 .69 .81 .94 

Percent of weeks Cocaine Used During Pregnancy 
Figure 4. 2: Percent of Weeks Cocaine Used During Pregnancy, n=115 



Table 4. 4: Biological Mothers Drug 


Use by Cocaine Exposure Status, n=308 




Non- 
Exposed 

n=154 


Cocaine 
Exposed 

n=154 


Total 
Sample 

N=308 


Chi-Square 
Test 

p-values 


Percent of Weeks 
Cocaine Used 
During Pregnancy 


— 


0.47+/-.30 


— 


— 


Marijuana Use 


7.1% 
(11) 


44.2% 
(68) 


25.6% 
(79) 


.000 


Tobacco Use 


24.0% 
(37) 


79.9% 

(123) 


51.9% 
(160) 


.000 


Alcohol Use 


30.5% 

(47) 


76.6% 
(118) 


53.5% 
(165) 


.000 






46 

Outcome Measures: Behavior and Development 

The multidimensional approach outlined in the previous chapter will be used to 
assess the differences in the behavior and development of prenatally and non-prenatally 
cocaine exposed children. The score on the Vineland Adaptive Behavior Scales 
(Sparrow, Balla, & Cicchetti 1984) will be used as a measure of behavior. The score on 
the Bayley Scales of Infant Development will be used to measure the children's 
development. 

Behavior. The Vineland scale was designed to measure the personal and social 
adaptability of handicapped and non-handicapped individuals from birth through 
adulthood (Holden 1984). During a visit to each child's home, the instrument was 
administered to each child's primary caregiver in the form of a semi -structured interview. 
The Vineland was scored and interpreted by a trained test administrator upon its 
completion. 

The Vineland survey consists of 297 items that cover four behavioral domains: 
(1) communication (receptive and expressive language); (2) daily living skills (self-care 
activities); (3) socialization (interpersonal relations and play activities); and (4) motor 
skills (gross and fine motor coordination). The standard scores range from to 200 with 
higher scores reflecting higher levels of competence (Sparrow, Balla, and Cichetti 1984). 
Each primary caregiver reported whether or not her child performed the tasks 
satisfactorily and habitually or if the skill was emerging and/or adequately performed. If 
there had not been an opportunity to observe the child performing the tasks, the task was 
not included in the total score for that domain. 

The standard scores for the Vineland were developed using a national 
standardized sample of 3,000 subjects drawn from a pool of 21,876 potential participants 



47 

representing the 1980 US Census figures by race, sex, community size, geographic 
region, and parental education (Holden 1984). The developers of the Vineland report 
test-retest correlations ranging from 0.98 to 0.99 and interrater reliability correlations 
ranging from 0.96 to 0.99 (Sparrow, Balla, and Cichetti 1984). The construct validity 
was reported as satisfactory based on an increase in raw scores for each age group, 
significant factor loading, and positive correlations with other intelligence scales, such as 
the Peabody Picture Vocabulary Test (Sparrow et al. 1984). 

Development. The Bayley Scales of Infant Development (Bayley 1969) were 
designed for use in both clinical and research practices by Nancy Bayley in 1969. It 
provides an assessment of each child's developmental status in comparison to national 
norms. The scales were standardized on a stratified sample of non-institutionalized 
children selected from the 1960 United States Census. Almost 40 years after its 
inception, the Bayley Scales are still widely used among researchers. The primary 
strengths of the instrument are its norms that controlled for sex, race, urban versus rural 
residence and parental education, as well as its significant correlation with other 
intelligence scales such as the Stanford Binet (Whaley 1984). 

A study by Werner and Bayley (1966) reports respectable statistical properties for 
the Bayley. Split-half reliabilities were reported for the mental and motor scales. The 
Spearman correlation coefficients for the mental scale ranged from 0.81 to 0.93 with a 
median of 0.88. The motor scale has resulting coefficients of 0.68 to 0.92 with a median 
value of 0.84. The test-observer and test-retest reliabilities were also favorable. The 
mean percentage of agreement between observers on the mental scale was 89.4 (standard 
deviation = 7.1) and 93.4 (standard deviation = 3.2) on the motor scale. The test-retest 



48 

reliability score for the mental scale was reported as 0.76; however, the motor score was 

not reported in the review (Whaley 1984). 

In this study, a clinician completed the Bayley during the children's three-year 

follow-up at the hospital or clinic. The clinician used the Bayley to assess each child's 

mental and motor skills. Like the Vineland, the standard scores on the Bayley range from 

to 200 where higher scores reflect a higher level of competence (Bayley 1969). The 

mean on the mental and motor index is 100 with a standard deviation of 16. Interpreters 

of the Bayley and the Vineland have placed the scores in the following range: Low (less 

than 69), moderately low (70-84), adequate (85-115), moderately high (116-130), and 

high (131 or above). 

Hypothesis 1 : Based on my review of the biomedical and behavioral 
literature on the effects of prenatal cocaine exposure, I hypothesize that in 
a bivariate analysis, the children who have been prenatally exposed to 
cocaine will have lower scores on both the Vineland and the Bayley than 
children who have not been prenatally exposed to cocaine. However, this 
prediction changes when the neonatal and postnatal factors are considered. 

Neonatal Risk: Newborn Health Status 

Based on biomedical and behavioral research there is a relationship between poor 
health at birth and poor developmental outcomes in infancy and in some cases early 
childhood. Each child's risk of experiencing physiological problems that require medical 
attention was assessed at birth using the Hobel Perinatal Complications Scale (Hobel, 
Hyvarinen, Okada & Oh 1973). Medical personnel determined each child's neonatal risk 
after reviewing the mother and child's medical records, which included an assessment of 
prenatal risk, neonatal risk, and an assessment of the complications incurred during labor 
and delivery. The scores on these assessments indicate each child's risk of experiencing 
health problems that may require medical attention in the future. 



49 

The neonatal risk score ranges from to 35. A score of 10 or higher indicates a 

greater risk of having physiological problems during infancy and beyond. In order to test 

the reliability of the instrument, Hobel and his associates (1979) tested the scale's ability 

to predict infant mortality. They found that the neonatal risk score predicted infant 

mortality correctly 82.5% of the time (Hobel, Youkeles & Forsythe 1979). Hence, 

children with lower risk scores should experience better health outcomes, thus 

compensating for the risk associated with prenatal cocaine exposure. 

Hypothesis 2: Using the multidimensional model, I predict that regardless 
of cocaine exposure status, fewer neonatal risks will result in higher scores 
on the adaptive behavior and developmental scales. Additionally, the 
neonatal risk will serve as a significant predictor of adaptive behavior and 
development when included in the multidimensional model. 

Postnatal Factors: Social Ecological Model 

The postnatal environment reflects the social ecological model adapted from 
Bronfenbrenner's (1979) work. Using Bronfenbrenner's ecological model of human 
development as a guide, I have constructed four systems or dimensions that characterize 
the postnatal environment: the micro-, meso-, exo-, and macrosystems. The 
microsystem represents the setting closest to the child and it is operationalized using a 
measure of the primary caregiver's psychosocial status. The mesosystem characterizes 
the relationship between the child and his or her home environment. According to 
Bronfenbrenner, the exosystem reflects the setting that does not directly involve the child, 
but may have an influence on the child's development. It is operationalized as the 
family's social support system. Last, the macrosystem is comprised of a measure of the 
child's race and the family's household income. 

At age three, 26.5% (n=62) of the children in the total sample do not live with 
their biological mother (see Table 4.5). In each case, the individual who had custody 






50 



and/or who was primarily responsible for the child's care has been classified as the 
child's primary caregiver. The responses from the interview with the primary caregiver 
are used to construct the variables in the social ecological model, which represents the 
postnatal environment, the second compensatory factor in the multidimensional model. 



Table 4. 5: Caregiver's Relationship to Child at Age Three by Cocaine Exposure Status 





Non- 
Cocaine 
Exposed 

n=119 


Cocaine 
Exposed 

n=115 


Row 
Percents 

n=234 


Z-Test 
Statistic 

p-value 


Biological Mother 


66.3% 
(114) 


33.7% 
(58) 


100% 
(172) 


-7.844 
0.000 


Biological Father 


12.5% 
(1) 


87.5% 
(7) 


100% 
(8) 


-2.203 
0.028 


Adopted Mother 


— 


100% 

(5) 


100% 
(5) 


-2.294 
0.022 


Grandmother 


13.3% 
(2) 


86.79? 
(13) 


100% 
(15) 


-2.998 
0.003 


Other Relative 


-- 


100% 
(12) 


100% 
(12) 


-3.610 
0.000 


Foster Mother 


9.1% 

(2) 


90.9% 

(20) 


100% 

(22) 


-4.108 

0.000 



Microsystem: Primary Caregiver's Psychosocial Status. Each child's primary 
caregiver's psychosocial status is determined by her score on the Center for 
Epidemiologic Studies - Depression Scale (CES-D). The CES-D is a self-report of 
depressive sympotomology designed for use in research settings with non-clinical or non- 
psychiatric populations. It consists of twenty questions rated on a four-point scale. Each 
question indicates how frequently the respondent experienced a particular set of 
symptoms during the past week. Factor analysis reported by Radloff (1977) indicates 
that the CES-D can be broken into four dimensions: positive affect, negative affect, 



51 

somatic concerns, and interpersonal concerns. However, given the high degree of 
internal consistency, it is recommended that a total score be used in statistical analysis. 

A total score of 16 typically points to the presence of depressive symptomology. 
A score below 16 suggest that the individual is probably not at risk for depression. A 
score between 16 and 20 means the individual has expressed mild depressive 
symptomology. A score ranging from 21 to 30 reflects a risk of experiencing moderate 
depression and a score of 31 or above indicates severe risk of receiving a diagnosis of 
depression. However, it is duly noted that this is not a clinical assessment, but a 
diagnostic tool or screen to measure depressive symptoms in the general population 
(Devins and Orme 1984). 

The test was created in the early 1970s and tested on randomly selected adults 
living in households chosen from a probability sample of households in Kansas City, 
Missouri or Washington County, Maryland. Numerous researchers have reviewed the 
psychometric properties of the CES-D. Initial reports by Devins and Orme (1984) on the 
test-retest reliability appear quite low (two week estimate r = 0.51; four week estimate r = 
0.67), but it is presumed that the low scores are due to the fact that the scale measures 
symptoms that occurred within the last week. So, as people and their life circumstances 
change, the results from one week to the next are expected to change as well. 

The internal consistency is a more useful measure of reliability for an instrument 
that measures changing states or moods such as the CES-D. Using Cronbach's alpha, 
Radloff (1977) reports Pearson correlation coefficients of 0.84, 0.85 and 0.90 meaning 
that the items in the instrument all appear to be measuring the same construct. 



52 

Weissman and associates (1977) tested the construct validity of the CES-D by 
testing individuals undergoing psychiatric treatment. It was reported that the depressed 
group in the sample received higher scores on the CES-D than the recovered and non- 
depressed groups. Additional studies confirm the construct validity of the CES-D by 
comparing the results of the CES-D to those of other depression scales. The CES-D is 
reportedly highly correlated with the Symptom Checklist 90, another scale designed to 
measure psychological distress and depressive symptomology. The correlation 
coefficients ranged from 0.70 to 0.80 (Derogatis, Lipman, and Covi 1973). 

Hypothesis 3: Using the multidimensional model, I predict that regardless 
of cocaine exposure status, the primary caregivers' score on the CES-D 
will be correlated with the adaptive behavior and developmental scores for 
their child. As the number of depressive symptoms increases, the scores 
on the adaptive behavior and developmental skills scales will decrease. 
Additionally, the primary caregiver's depression status will serve as a 
significant predictor of behavior and development in the multidimensional 
model. 

Mesosystem: Home Environment. The mesosystem will be measured by 
assessing the physical and parenting environments in the home of the child. The physical 
and parenting environment will be operationalized using Caldwell and Bradley's (1979) 
Home Observation for Measurement of the Environment (HOME) Inventory. The 
HOME was completed during the interview with the primary caregiver. The interviewer 
completed the HOME by asking each caregiver questions and by observing the family's 
behavior and the nature of the environment. The HOME was designed as a standard way 
for researchers to ascertain the nature and quality of the physical and parenting 
environment as they relate to children's cognitive development. 

The HOME scale was standardized on families in Little Rock, Arkansas and 
Syracuse, New York. The sample was not random or stratified, but the researchers did 



53 

over sample low income and Black families. The revision of the HOME, which took 
place in 1984, was tested on 232 families in Little Rock of whom 30% were welfare 
recipients, 66% were Black, and the average level of education was 1 1 years of 
schooling. The version of the scale designed for children of this age consists of eight 
subscales: learning stimulation, academic stimulation, physical environment, variety in 
experience, language stimulation, warmth and acceptance, modeling, and acceptance. The 
Kuder-Richardson reliability estimate for the total scale is 0.93 and the test-retest 
reliability ranges are as high as 0.70 depending on the subscale (Procidano 1985). 

For purposes of this study, the home is divided into two factors: the parenting 
environment and the physical environment. The parenting environment consists of the 
items on the HOME that measure the primary caregiver's interaction with the child 
within the home. The physical environment consists of the items that measure the 
homes' physical attributes. Two factor analyses were conducted to determine the 
viability of these two domains. 

The factor loadings for the parenting dimension ranged from 0.56 to 0.78. The 
eigenvalue was 2.56 and it explained 51.25% of the variance. The language stimulation, 
warmth and acceptance, academic stimulation, modeling, and acceptance subscales, 
which make up the parenting factor, maintained statistically significant correlations of 
0.74 or greater with the parenting factor. 

The factor loading for the physical dimension ranged from 0.66 to 0.81. The 
eigenvalue was 1.77 and it explained 58.98% of the variance. The physical dimension 
consists of the learning stimulation, physical environment, and variety in experience 



54 

subscales. Each of these maintained statistically significant correlations with the 

parenting dimension ranging from 0.66 to 0.82. 

In this study, the scores on the parenting dimension range from 1 to 6 with a mean 

of 4.26 (standard deviation = .89). The physical dimension ranges from 1 to 6 with a 

mean of 5.67 (standard deviation = 1.60). The higher the score, the more positive 

attributes found in the home environment. 

Hypothesis 4: Using the multidimensional model, I predict that regardless 
of cocaine exposure status, the parenting environment and the physical 
environments will be correlated with the adaptive behavior and 
developmental scores. As the number of positive attributes in each 
dimension increases, the scores on the adaptive behavior and 
developmental skills scales will increase. Additionally, the parenting and 
the physical environments will serve as significant predictors of behavior 
and development in the multidimensional model. 

Exosystem: Family and Social Support System. The exosystem refers to the 
quality of the family's social support system. The families' social support system is 
measured using the Family Social Support Scale (FSS). The FSS scale measures the 
existence of particular family and community support networks and how helpful they 
have been to the family during the last twelve months (Dunst 1985). The primary 
caregiver is asked to indicate on a 19-item list how helpful immediate and extended 
family members and community and professional agencies have been in the past year. 
The family members included in the survey include those of the child and the child's 
primary caregiver. Using a likert scale ranging from (not at all helpful) to 4 (extremely 
helpful) each supporter is ranked with the exception of those who do not apply. The total 
score is computed by adding up each rank. In this study, the scores on the Family 






55 

Support Scale ranged from 12 to 76 with a mean of 38.43 (standard deviation = 1 1.96). 

The scale is an assessment of the quality of the support available to the primary caregiver. 

Dunst, Trivette, and Jenkins (1988) report promising psychometrics from a study 

of 139 parents of pre-school children with developmental disabilities. The alpha 

coefficient for the measure of validity was 0.77. The split-half reliability measured by 

the Spearman-Brown formula was 0.77 and the Pearson test-retest reliability coefficient 

after one month was reported as 0.75. 

Hypothesis 5: I predict that regardless of cocaine exposure status, the 
quality of family support will be correlated with adaptive behavior and 
development. As the number of positive supports available to the family 
increases, the scores on the adaptive behavior and developmental skills 
scales will increase. Additionally, I hypothesize that the family support 
dimension will serve as a significant predictor of behavior and 
development in the multidimensional model. 

Macrosystem: Social Structural Variables. In most sociological research, 
demographic characteristics are added into the analysis with very little thought about the 
intricate connection between sociodemographics and outcomes. There is enough 
empirical evidence available to support the contention that structural variables such as 
race, class, and gender do matter (Allport 1988; Davis 1991; Hacker 1992; West 1993). 
Bronfenbrenner describes the macrosystem as the setting that represents the culture or 
subculture in which the other settings or systems reside. He predicts that the nature of the 
micro-, meso-, and exosystems will vary depending on the characteristics of the 
macrosystem. For example, "homes, day care centers, neighborhoods, work settings, and 
the relations between them are not the same for well-to-do families as for the poor" 
(Bronfenbrenner 1979: 26). 

In this study, I have constructed four dummy variables that represent the race and 
economic status of each family. The race of the family is determined by the race of the 



56 

biological mother. Each biological mother was classified as either Black or non-Black 
based on self-reports, upon enrollment into the study. I realize this is a crude estimate of 
the family's race, but unfortunately, the official racial classification of the children and 
their primary caregivers was unavailable. However, one could argue that in most cases a 
child's race is determined by his or her biological mother's race (unless the biological 
father is Black and the mother is not Black, whereas the child is typically classified as 
Black); therefore, using this classification is not completely unreasonable. 

The families' household income was collected during the home interview. Each 
primary caregiver was asked to classify her families' entire household income into one of 
five categories: (1) $0 to $6,000, (2) $6,001 to $12,000, (3) $12,001 to $18,000, (4) 
$18,001 to $24, 000, and (5) $24,000 or more. I used these categories to construct a 
poverty variable. The poverty variable measures whether or not the family is living at or 
below the poverty line based on the 1998 poverty threshold of $16,600 for a family of 4 
(NCCP 2000). I took the largest number in each range and divided it by the number of 
people living in the household. This number was then measured against the poverty line 
and those families with household incomes equal to or below $16,600 were classified as a 
"1" meaning below poverty and those who had an income of $16,601 or greater were 
classified as a "0" or above poverty. 

The poverty variable was then added to the race variable to create four dummy 
variables: BlackPoverty (family with a Black child living below poverty), Non- 
BlackPoverty (family with a Non-Black child living below poverty), BlackAbove (family 
with a Black child living above poverty) and Non-BlackAbove (family with a Non-Black 



57 

child living above poverty). The BlackPoverty variable is the referent group in the 

multidimensional model. 

One of the strengths of the data used in this study is the existence of a matched 

sample of cocaine and non-cocaine exposed children. The cocaine using and non-cocaine 

using women were matched on race, parity, perinatal risks, and socioeconomic status at 

the time of enrollment (see Table 4.1). Therefore, no significant differences exists 

between the cocaine and non-cocaine exposed children in terms of their 

sociodemographics at birth. At age three, still there are no statistically significant 

differences between the two groups' race (z=-0.292; p=0.770) and household incomes 

(z=-0.695; p=0.487). 

Hypothesis 5: Using the presumed significance of race and class in the 
social ecological model, I hypothesize that the families with a non-Black 
child and higher household incomes will have children who perform better 
on the behavioral and developmental scales than Black or non-Black 
children living with impoverished families. In the multidimensional 
model, I predict that the NonBlackAbove variable will be a stronger 
predictor of behavior and development than the other Racelncome dummy 
variables given that BlackBelow is the reference group. 

Summary 

The basic hypothesis presented in this chapter is that, regardless of children's 

cocaine exposure status, the postnatal environment is a significant predictor of behavioral 
and developmental outcomes for pre-school aged children. The multidimensional model 
summarizes the relationship between the prenatal, neonatal, and postnatal environment. I 
predict that factors in the neonatal and the postnatal environment will compensate for the 
risk associated with the prenatal environment, thus reducing the effects of prenatal 
cocaine exposure on early childhood outcomes. I expect that in the bivariate analysis 
presented in the following chapter, that the effects of prenatal cocaine exposure will be 



58 

minimal due to the strength of the other risks associated with this group of children. The 
multivariate analysis is expected to indicate which biomedical and social ecological 
factors measured in this study will explain differences in behavioral and developmental 
outcomes. 

In the next chapter, I test each of the above hypotheses within the context of the 
multidimensional model. Table 3.1 lists the measures that are used to operationalize 
each dimension in the model. The table outlines the constructs representing each 
dimension and the standardized instruments used to measure each construct. 









59 



Table 4. 6: Description of Variables in Multidimensional Model 



VARIABLES 


DESCRIPTION 


MEASURES 


Dependent Variables (Scale) 


Adaptive Behavior 
(0-200) 


A composite score obtained from 
a behavior rating scale. 


Vineland Adaptive Behavior Scales 
(Sparrow, Balla, & Cicchetti 1984) 


Development 
(0-200) 


A composite score obtained from a 
developmental rating scale. 


Bayley Scales of Infant Development 
(Bayley 1969) 


Prenatal Dimension 


Cocaine Status 
No=0; Yes=l 


Cocaine or non-cocaine exposed child 
targeted for the research study. 


Prenatally Exposed 


Neonatal Dimension 


Infant Risk Factors 
<10=risk 


Measure a newborns risk of poor health 
outcomes. 


Hobel Neonatal (Hobel, Hyvarinen, 
Okada, & Oh 1973; Hobel, Youkeles, & 
Forsythe 1979) 


Postnatal Dimension 
(Social Ecological Factors) 


Microsystem 


Psychological 

Characteristics 

<16=risk 


Measure of the primary 
caregivers' risk for depression. 


Center for Epidemiologic Studies 
Depression Scale (CES-D) (Radloff, 
1977) 


Mesosystem 


Parenting Environment 
(0-6) 


What are the nature, quality, and 
quantity of the interaction 
between the primary caregiver 
and the child in the home? 


HOME Subscales II, IV, V, VI, VIII 
(Caldwell & Bradley 1984) 


Quality of Home 

Environment 

(0-6) 


The nature of the family's 
physical residence, including 
assessments of safety, nurturing, 
and developmental stimulation. 


HOME subscales I, III, VII (Caldwell & 
Bradley 1984) 


Exosystem 


Family Support System 
(0-76) 


The quality of support provided to 
primary caregiver from others. 


Family Social Support Scale (Dunst, 
Jenkins, & Tivette 1984) (Dunst, Trivette, 
& Deal 1988) 


Macrosystem 


Sociodemographic 
Characteristics 
NonBlack=0;Black=l; 
NotPoor=0; Poor=l 


Social and demographic 
description of the primary 
caregiver and child. 


Child's Race 
Household Income 






CHAPTER 4 
DATA ANALYSIS AND RESULTS 



Analytical Procedures 

In this chapter, I present the findings from the bivariate and multivariate analyses 
of the multidimensional model. Each measure included in the model is presented in 
terms of the differences between the prenatally cocaine exposed (PCE) and non-PCE 
groups using the Mann-Whitney test. The Mann-Whitney test is a nonparametric test 
equivalent to the t-test, but it does not require that the sample meet the strict assumptions 
of a t-test. Nonparametric procedures are useful for studies like this one because of its 
small non-normally distributed sample. The Mann-Whitney test assumes identical shapes 
when comparing the population distributions, but it does not require the populations to be 
"normal" or to be centered around the mean. The Mann-Whitney test is more powerful 
than a median test since it uses the ranks of the cases. It requires an ordinal level of 
measurement. The resulting mean rank sum is called U. The U represents the number of 
times a value in the first group is smaller than a value in the second group, when values 
are sorted in ascending order (Agresti and Finlay 1986; Hildebrand 1986; SPSS 2001). 

In addition to analyzing the differences between the prenatally cocaine and non- 
cocaine exposed infants on the measures of their neonatal and postnatal social 
environments, the relationship between each environmental factor is analyzed using the 
Spearman's correlation coefficient. Spearman is a nonparametric version of the Pearson 



60 



61 

correlation coefficient. It is based on the ranks of the data rather than the actual values. 
Like the Pearson's correlation coefficient, the values of the coefficient range from -1 to 
+ 1 where the sign of the coefficient indicates the direction of the relationship. The 
absolute value indicates the strength of the relationship with larger absolute values 
indicating stronger relationships between variables (SPSS 2001). 

The multivariate analysis includes the measures of the prenatal, neonatal and 
postnatal environment as biomedical, behavioral and social predictors of behavior and 
development. Using generalized linear regression which allows the response variable to 
have a non-normal distribution, I have created three models of behavior and three models 
of development. The standardized regression coefficients are presented in order to 
demonstrate the relative strength of each predictor in each model. The higher the 
standardized regression coefficient and the smaller the p-value, the stronger the predictor. 
The first model includes the measure of prenatal risk or prenatal cocaine exposure as a 
predictor of either behavior or development. The second model adds the neonatal factor 
or the measure of health risks and the third model includes the prenatal, neonatal and the 
postnatal factors as predictors of behavior and of development. These models reflect the 
proposed additive or compensatory influence each factor has on pre-school aged 
children's behavior and development. 

The analysis begins with the questions posed in the introductory chapter. First, is 
there a difference in the behavior or the development of PCE children and non-PCE 
children? Second, to what extent do neonatal and postnatal factors hinder or enhance 
behavioral and developmental outcomes among this group of "at-risk" children? 



62 

Differences between PCE children and non-PCE children 
Birth Characteristics 

In chapter 4, 1 described the characteristics of the longitudinal sample at birth. 
The number of subjects used in this study has been reduced from 308 to 234, in order to 
have complete data on each of the measures included in the multidimensional model. 
The following table describes the characteristics of the reduced sample at birth. 



Table 5. 1: Birth Outcomes by Cocaine Exposure Status, Means+/-Standard Deviations 
(Mean Rank) 





Non-Cocaine 

Exposed 

n=119 


Cocaine 

Exposed 

n=115 


Total Sample 

N=234 


Mann- 
Whitney 
p-values 


Female 
Infants 


0.43+/-0.05 
(112.64) 


0.53+/-0.05 
(122.53) 


0.47+/-0.50 


0.197 


Premature 
Infant = Yes 


0.08+/-0.28 
(114.83) 


0.13+/-0.34 
(120.26) 


0.11+/-0.31 


0.252 


Infant's Birth 
Weight 


3179.9+/-618.7 
(126.7) 


2985.5+/-614.2 
(108.0) 


3130.5+/-620.2 


0.034 


Hobel 
Prenatal 


44.62 +/-19.36 
(124.47) 


54.61 +/-17.47 
(176.04) 


49.53+/-19.08 


0.000 


Hobel Labor & 
Delivery 


19.75 +/17.44 
(148.63) 


18.96 +/14.44 
(151.40) 


19.36 +/-16.01 


0.789 


Hobel 
Neonatal 


15.43 +A29.93 
(142.64) 


15.64 +1-2 1.46 
(157.51) 


15.54 +/-26.06 


0.107 



When compared to the longitudinal sample described in Table 4.2, the mean 
percentage of females in the sample has not changed (47%), even though the significance 
level has changed due to the smaller sample size. The difference in the number of 
premature births for the PCE and non-PCE groups has changed. There are fewer 



63 

premature children in the reduced sample and the difference between the non-PCE and 
non-PCE groups is no longer statistically significant (p=0.252). There is a statistically 
significant difference between the two groups in terms of mean birth weight for the 
children, however this sample indicates that the average birth weight of the children 
included in the three year follow up is higher than the initial longitudinal sample. 

The differences between the initial longitudinal sample and the children included 
in the three year follow up are subtle, but they do indicate that the children with higher 
birth weights and fewer perinatal complications were more likely to have completed all 
assessments at age three. Unfortunately, this is a consequence of doing longitudinal 
research with human subjects that is very difficult if not impossible to control. The 
families that are most accessible are typically the ones who are engaged in research and 
from these numbers those families tend to be the ones with stronger or healthier children, 
a fact that is true for most research, but is often negated. The researchers made a special 
effort to control for the social demographics and health related risks that may confound 
any observed differences between the PCE and non-PCE children, but it is difficult to 
control for attrition. Therefore, it is important to keep in mind that the conclusions 
drawn in the following analyses reflect the differences between the two groups of the 
families who were engaged in this research project, but they may or may not reflect the 
general population. 
Neonatal Environment 

Maternal drug use during pregnancy is one of the items used to construct the 
Hobel Perinatal Complications Scale. It is expected that children who were prenatally 
exposed to any type of illicit drug or alcohol will have more health problems than their 
non-exposed counterparts. The neonatal assessment represents the risk of health 



64 

complications for the newborn infant, while the prenatal score is an assessment of 
prenatal risk to the fetus and the labor and delivery score is used to determine the risk of 
complications that the mother and child may encounter during delivery. Only the 
neonatal assessment score is used in the multivariate analysis, because it encompasses the 
prenatal and the labor and delivery risk scores. In this sample of "at-risk" children, there 
is no statistically significant difference between PCE children and the non-PCE 
children's mean score on the neonatal complications scale (z=-1.61 1; p=0.107). 

The neonatal score of the PCE children (mean=15.6; standard deviation=21.5) is 
slightly higher than the non-PCE children (mean=15.4; standard deviation=29.9), but this 
difference is only approaching statistical significance, whereas the difference between the 
PCE (mean=54.6; standard deviation=17.5) and non-PCE children (mean=44.6; standard 
deviation=19.4) on the prenatal risk assessment is significantly different (p=0.000). 
Hence, as time passes, among the fetuses that survive the pregnancy and the infants who 
survive the birthing process, the health risk associated with prenatal cocaine exposure 
dissipate. But, it is important to note that both groups have neonatal risk scores above 10, 
which indicates considerable risk for health complications during infancy and early 
childhood. 



65 



Mean 



60 



50 



40 



30 



20 



10 



1 

1 
1 
I 
1 







Non-PCE 
n=119 



N=234 



PCE 
n=115 



Hobel Prenatal 



~|Hobel Labor & 
Delivery 



iHobel Neonatal 



Figure 5.1: Hobel Complications Scale by Prenatal Cocaine Exposure Status 

Postnatal Environment 

Within the postnatal environment, prenatal cocaine exposure has even less 
association with the nature of the environment. As shown in Tables 5.2 and 5.3, there are 
minimal differences between the PCE and non-PCE children in terms of their social 
environment as measured using the social ecological factors. 






66 

Microsystem. According to the results on the Center for Epidemiologic Studies- 
Depression scale (CES-D), there is a statistically significant difference between the 
depression status of the primary caregivers with PCE children and those with non-PCE 
children. The primary caregivers with non-PCE children have slightly higher scores on 
the CES-D (mean = 22.88; standard deviation=9.17) than the primary caregivers with 
PCE children (mean = 19.97; standard deviation = 10.77). Both groups received scores 
above 16, which typically indicates a risk for depression. On average, both groups of 
caregivers reflect a moderate risk for depression, a trend that is also related to whether or 
not the primary caregiver is the biological mother or not. Non-cocaine exposed children 
are more likely to be living with their biological mother than cocaine exposed children 
(chi-square = 75.97, p=0.000). This relationship between prenatal cocaine exposure and 
parental status is explored further in the section of this chapter that describes the 
relationships between the environmental factors and outcomes. 

Mesosystem. The nature of the home environment was measured using the 
HOME scale. If one were to assume that women who used drugs during their pregnancy 
are less likely to live in and/or maintain stable and nurturing households due to their drug 
behavior, then it would be safe to postulate that the children who were prenatally exposed 
to cocaine would live in poorer home environments. However, among the children in this 
sample, very few of the PCE children still live with their biological mother at age three. 
So, this hypothesis can not be fully evaluated. 



67 



Table 5. 2: Postnatal Differences between PCE and non-PCE 


children at the 




Microsystem and Mesosystem Level, Mean +/- Standard Deviation (Mean Rank 


) 




Non-Cocaine 


Cocaine 


Total 


Mann 




Exposed 


Exposed 




Whitney 




N=119 


N=115 


N=234 


p-value 


Microsystem - Psychosocial Dimension 


CES-Depression Scale 


22.88+/-9.17 
(127.78) 


19.97+/-10.77 
(106.87) 


2 1.45+/- 10.07 


0.018 


Mesosystem - Home Environmental Dimension 


Physical Environment 


5.63+/-1.57 
(116.71) 


5. 71+/- 1.65 
(118.32) 


5.67+/- 1.60 


0.856 


Home I: 


5.61+/-2.63 


6.11+/-2.75 


5.86+/-2.70 


0.222 


Learning Stimulation 


(112.22) 


(122.97) 






(0-11) 










Home III: 


5. 46+/- 1.81 


5.25+/- 1.87 


5. 36+/- 1.84 


0.310 


Physical Environment 


(121.76) 


(113.10) 






(0-7) 










Home VII: 


5.81+/-1.68 


5. 76+/- 1.62 


5.78+/-1.65 


0.755 


Variety in Experience 


(118.83) 


(116.12) 






(0-9) 










Parenting Environment 


4.59+/-0.96 
(115.79) 


4.70+/-0.10 
(119.27) 


4.26+/-0.89 


0.694 


Home II: 


6.26+/- 1.01 


6.30+/- 1.04 


6.28+/- 1.02 


0.579 


Language Stimulation 


(115.34) 


(119.73) 






(0-7) 










Home IV: 


5.17+/-1.55 


5. 49+/- 1.65 


5.32+/- 1.60 


0.041 


Warmth and Acceptance 


(108.82) 


(126.48) 






(0-7) 










Home V: 


3.73+/- 1.26 


4.06+/- 1.08 


3. 89+/- 1.1 8 


0.058 


Academic Stimulation 


(109.64) 


(125.63) 






(0-5) 










Home VI: 


3. 22+/- 1.66 


2.95+/- 1.31 


3. 09+/- 1.24 


0.117 


Modeling 


(124.13) 


(110.64) 






(0-5) 










Home VIII: 


2.82+/- 1.20 


.65+/- 1.1 2 


2.74+/- 1.1 6 


0.131 


Acceptance 


(123.81) 


(110.97) 






(0-4) 











There are no significant differences between the PCE and non-PCE children's 
parenting environments or their physical home environments, with one exception. The 
parenting environment of the PCE children is slightly higher on the measure of maternal 
warmth and acceptance (p = 0.041) and academic stimulation (p = 0.058). These 



68 

differences indicate that the prenatally cocaine exposed children are living with primary 
caregivers who show more warmth and acceptance and provide more academic 
stimulation than the primary caregivers of the non-PCE children. The fact that most of 
the primary caregivers for the PCE children are not the biological mothers makes this 
finding quite interesting. Yet, further analysis did not show a relationship between the 
different subdomains on the HOME and the caregiver status of the biological mother. 
Across the different domains of the HOME, the physical home environment and the 
parenting environment of the PCE and non-PCE groups is not significantly different, nor 
is it different when controlling for the caregiver status of the biological mother. 

Exosystem. The exosystem is measured using the Family Social Support Scale. 
This scale assesses the quality of the social support available to the primary caregiver. 
Within this study sample, the primary caregivers with a non-cocaine exposed child had a 
mean level of support of 39.31 (standard deviation = 10.93) and the primary caregivers 
with a prenatally cocaine exposed child had a slightly lower level of support at 37.52 
(standard deviation = 12.92). These differences were not statistically significant 
(p=0.1 12), but they do represent a relatively low level of social support. On a scale of 
to 76, the mean level of support for both groups was only 38.43 with a standard deviation 
of 11.96. 

Due to how the social support scale is defined in different studies, it is difficult to 
ascertain what a "normal" level of support is for "at-risk" families. The range of support 
varies from one population to another depending on how many supports are available to 
the family, but a mean that falls at or below the midpoint of 38 indicates that there is 



69 

either a low level of support available to these families and/or the available supports are 
not necessarily helpful (see Table 5.3). 



Table 5. 3: Postnatal Differences between PCE and non-PCE 
and Macrosystem Level, Mean +/-Standard Deviation (Mean 


children at the Exosystem 
Rank) 




Non-Cocaine 
Exposed 

n=119 


Cocaine 
Exposed 

n=115 


Total 
n=234 


Mann- 
Whitney 

p-value 


Exosystem - Family Soci 


al Support Dimension 






Family Support Scale 
(12.00 - 76.60) 


39.31+/-10.93 

(124.40) 


37.52+/-12.92 
(110.36) 


38.43+/-11.96 


0.112 


Macrosystem - Social Sti 


•uctural Dimens 


ion 






Child's Race=Black 


0.83+/-0.38 
(118.31) 


0.82+/-0.39 
(116.63) 


0.82+/-.38 


0.770 


Families Living Below 
Poverty 


0.71+/-0.45 
(121.07) 


0.65+/-0.48 
(113.80) 


0.68+/-.47 


0.308 


Black Below Poverty 


0.68+/-0.47 
(122.14) 


0.60+/-0.49 
(112.70) 


0.64+/-0.48 


0.199 


Black Above Poverty 


0.15+/-0.36 
(113.70) 


0.22+/-0.41 
(121.43) 


0.18+/-0.39 


0.193 


Non-Black Below 
Poverty 


0.03+/-0.18 
(116.43) 


0.05+/-0.22 
(118.60) 


0.04+/-0.20 


0.484 


Non-Black Above 
Poverty 


0.13+/-0.34 
(117.73) 


0.13+/-0.34 
(117.26) 


0.13+/-0.34 


0.928 



Macrosystem. According to the tenets of urban sociology, poverty causes social 
disadvantages that can have a profound effect on the victim's health, behavior, and life 
course trajectory (Furstenberg, Cook, Eccles, Elder, and Sameroff 1999; Wilson 1987). 
By matching the two groups, the researchers were better able to control for the 
differences in birth outcomes caused by the cumulative effects of social disadvantage. 
There are no significant differences between the PCE children and the non-PCE children 
in terms of their race or household income by design. The majority (82%) of the children 



70 

in the sample are classified as Black and 68% of the families live below the poverty line 
with an income of less than $16,600 for a family of four. 

Sixty-four percent of the children are Black and living below poverty. Eighteen 
percent of the sample includes black children living above poverty. Non-Black children 
living below poverty make up 4% of the sample, while non-black children living above 
comprise 13% of the sample. Respectively, the majority of the Black children live below 
poverty and the majority of non-Black children live above poverty. 

Thus far, there have been very few differences between the PCE and the non-PCE 
children in this sample. The data indicates that there are slight differences in the 
characteristics of the home and the primary caregivers' psychosocial status; whereas the 
cocaine exposed children are residing with caregivers who are less likely to be depressed 
and who express more warmth and acceptance towards the child. Given the fact that the 
majority of the PCE children are not living with their biological mother at age three, these 
findings are interesting, but not antithetical. The better home environment among the 
PCE children suggests that the PCE children have not only been removed from their 
biological mothers, but they have been removed from less supportive environments as 
well. The findings presented thus far also indicate that the group of children included in 
this sample have considerably high neonatal risk scores, a greater likelihood of living 
with a depressed primary caregiver and in homes that can be considered less than perfect. 
Behavior and Development 

The next question asks whether there is a relationship between the child's 
environment and the child's behavioral and developmental outcomes. Despite the 
contradictory and inconclusive evidence in the literature on the effects of prenatal cocaine 
exposure, most people assume that children who have been prenatally exposed to cocaine 



71 

are developmental I y delayed resulting in severe behavior problems. The research 
findings presented here suggest otherwise. 

Among this sample of 234 children, there are no significant differences between 
the PCE children and the non-PCE children on any of the behavior or developmental 
domains measured by the Vineland Adaptive Behavior Scales (Vineland) or the Bayley 
Scales of Infant Development (Bayley). Table 5.4 shows the results for both scales and 
each of the subdomains. In fact, the PCE children actually have higher mean scores than 
the non-PCE children on the Vineland' s communication domain (p = 0.151), 
socialization domain (p = 0.091), and motor skills domain (p = 0.169). Even though 
these results do not represent a statistically significant difference, they are indicative of 
the trends mentioned earlier, whereas the PCE children are living with less depressed 
caregivers, in more nurturing home environments, with slightly higher household 
incomes than non-PCE children. 

However, as indicated in Table 5.4, the scores for both groups on the Vineland 
(mean = 98.5; standard deviation =14.7) and the Bayley (mean = 90.4; standard deviation 
= 15.4) are teetering between moderately low and average given the high standard 
deviation. Fifty-five percent of the children scored below 100, the national average, on 
the Vineland, while 72% received scores below the national average of 100 on the 
Bayley. The low performance on these nationally standardized tests indicate that this 
group of children, regardless of their cocaine exposure status is at risk of poor behavioral 
and developmental outcomes. This finding is inconsistent with the popular belief about 
the effects of cocaine exposure on behavior and development, but it is consistent with the 
belief that this group of children is at risk of developmental problems which could lead to 



72 

behavioral difficulties, for there is a significant correlation between the behavior and 
development (rho=0.473; p=0.000). 



Table 5. 4: Adaptive Behavior and Development by Cocaine Exposure Status, Means +/- 
Standard Deviations (Mean Rank) 





Non-Cocaine 
Exposed 

n=119 


Cocaine 
Exposed 

n=115 


Total 

N=234 


Mann- 
Whitney 

p-values 


Adaptive Behavior 
(Vineland) 
(Range: 20 -160) 


97.27+/- 14.19 
(113.12) 


99.81 +/- 15.16 
(122.03) 


98.51+/- 14.70 


0.314 


Communication 


98.22+/- 14.32 
110.74 


10 1.20+/- 13. 99 

123.43 


99.69+/- 14.20 


0.151 


Daily Living Skills 


103.23+/-14.05 
120.33 


101.63+/-14.77 
114.57 


101.52+/- 
13.79 


0.515 


Socialization 


97.68+/-12.62 
110.14 


99.92+/- 13.09 
125.11 


98.63+/- 12.06 


0.091 


Motor Skills 


95.32+/-16.13 
111.52 


96.50+/- 15.39 
123.69 


96.05+/- 15.62 


0.169 


Development 
(Bayley) 
(Range: 50- 150) 


90.59+/- 15.97 
119.63 


90.21+/- 14.88 
115.30 


90.40+/- 15.41 


0.624 


Motor Skills 


95.95+/- 18. 15 
121.53 


94.07+/- 18.06 
113.33 


95.02+/- 18.09 


0.354 


Mental Skills 


85.23+/- 16.79 
116.18 


86.35+/-15.62 
118.86 


85.78 +/- 16.20 


0.762 


Interpretation of Scales: Low (> 69), moderately low (70-84), adequate (85-115), 
moderately high (1 16-130), high (131 or above) 



So, if prenatal cocaine exposure does not explain the differences between children 
in terms of their behavior and development, what does? The multidimensional model 
suggests that the neonatal and postnatal environments compensate for the risk caused by 
the prenatal environment. In this next section, I explore the relationship between each 
environmental dimension, behavior and development, and the early childhood outcomes. 



73 

Environmental Factors and Early Childhood Outcomes 
Prenatal Risk and Outcomes 

In the bivariate analysis, PCE was not significantly con-elated with any of the 
social ecological factors from the postnatal environment with the exception of the 
primary caregiver's depression score (rho= -0.155; p=0.018). Apparently, the primary 
caregivers who were caring for a non-PCE child had higher scores on the depression 
inventory than the primary caregivers with a PCE child. This enigmatic finding may be 
better understood within the context of the relationship between the primary caregiver 
and the child. 

Approximately 50% of the PCE children did not live with their biological mother 
at age three, whereas only 4.2% of the non-PCE did not live with their biological mother 
at this same point in time. Hence, the non-cocaine using mothers are more likely to 
maintain custody of their children (rho=-0.514; p=0.000), and they are more vulnerable to 
depressive symptomology (rho=0.371; p=0.000) which is significantly correlated with the 
nature of the parenting environment (rho = -0.179; p=0.006), the physical environment 
(rho=-0.157; 0.017), family social support (rho=-0.185; p=0.005); and the family's 
poverty status (rho=-0.143; p=0.029) as shown in Table 5.5. Therefore, regardless of 
cocaine exposure status, the children in this study are "at-risk" of living in poor home 
environments with low quality social support, and limited economic resources when 
compared to the norms used in the standardization tables for each measure. 
Neonatal Risk and Outcomes 

Using the multidimensional model, I predict that there will be a relationship 
between the neonatal environment and behavior and development. The model infers that 
positive health outcomes for newborns results in better behavioral and developmental 



74 

outcomes for toddlers. While prenatal cocaine exposure poses a risk to behavioral and 
developmental outcomes, the neonatal and postnatal environment serve to compensate for 
prenatal complications. "At-risk" children who are born in a hospital, typically receive 
extra care and attention neonatally; and in the case of the cocaine exposed children, the 
extra care extends beyond their stay in the hospital. This is exemplified by the 
termination of parental rights for drug addicted mothers and/or the child's enrollment in 
social service programs designed to monitor the child's progress (i.e. Department of 
Children and Families). Hence, according to the compensatory model of resilience used 
to organize the multidimensional model, low neonatal health risk and a positive postnatal 
environment should compensate for the risk associated with a negative prenatal 
environment. 

In this sample of "at-risk" children, the neonatal risk score is significantly 
correlated with adaptive behavior (rho=-0.143; p=0.028) and it is marginally correlated 
with development (rho=-0.1 10; p=0.094) as shown in Table 5.5. As the number of health 
complications experienced by newborns decreases, the scores on the Vineland and the 
Bayley increase. In other words, children with fewer neonatal health complications tend 
to have better adaptive behavior at age three; whereas this is true for development but the 
relationship is not as strong. 

In terms of the relationship between the neonatal and postnatal environments, 
there is no significant relationship between the two. In the bivariate analysis, each of the 
three dimensions is independent of the other with one exception. A child's score on the 
neonatal health complications assessment is significantly correlated with the families' 
poverty status (rho=-0.132; p=0.044). The children with the greater number of neonatal 



75 

complications at birth are more likely to be living with a family that's average income is 
above the poverty line. Again, we encounter the relationship between risk and improved 
surroundings. The children with the greatest risk at birth, whether it was from prenatal 
cocaine exposure or some other contributing prenatal factor, appear to be living in better, 
less impoverished environments by the time they reach age three. 

Postnatal Factors and Outcomes 

In this section, I discuss the hypotheses pertaining to the social ecological model 
that represents the postnatal environment described in Chapter 4. It is presumed that the 
non-Black children living above poverty with psychologically stable caregivers who are 
more nurturing and who have better quality home environments and social support 
networks will exhibit better behavioral and developmental outcomes. This hypothesis is 
true to some extent. With the exception of the primary caregiver's psychosocial status, 
each dimension in the postnatal environment is significantly correlated with both 
behavior and development. The primary caregiver's level of depression is significantly 
related to development, but not to behavior. The children with lower developmental 
scores, tend to live with primary caregivers who report a higher level of depressive 
symptoms (rho=-0.129; p=0.049). The lack of a relationship between depression and 
behavior and the existing relationship between depression and development is quite 
interesting, but difficult to interpret due to the bi-directional nature of parent-child 
interaction. Do "problem" children cause caregivers to experience the symptoms of 
depression or does depression impair the caregivers' parenting capabilities? Further 
consideration is given to this dilemma in the subsequent chapter. 



76 



Table 5. 5: Correlation between Adaptive Behavior and Development, Prenatal Cocaine 
Exposure, and Environmental Factors, Spearman Correlation Coefficient, n=234 




Prenatal 

Cocaine 

Exposure 


Behavior 
(Vineland) 


Development 
(Bayley) 


Neonatal 
Health (Hobel) 


Prenatal 
Cocaine 
Exposure 


1.000 








Behavior 
(Vineland) 


.066 


1.000 


— 


— 


Development 

(Bayley) 


-.032 


473*** 


1.000 




Neonatal Risk 
Assessment 


.106 


-.143* 


-.110° 


1.000 


PCG Depression 
Scale 


-.155* 


-.071 


-.129* 


-.085 


Physical 
Environment 


.012 


324*** 


*) O "7 %. $z :fc 


.058 


Parenting 
environment 


.026 


O QT*** 


.276*** 


-.062 


Family Social 
Support 


-.104 


.160** 


.174** 


.018 


Child's Race 


-.019 


-.199** 


-.256*** 


.059 


Family below 
poverty 


-.067 


.000 


-.109° 


-.132* 


Black Below 
Poverty 


-.084 


-.022 


-.134* 


-.085 


Black Above 
poverty 


.085 


-.167** 


-.085 


.163* 


Non-Black 
Below Poverty 


.046 


.054 


.066 


-.102 


Non-Black 
Above Poverty 


-.006 


.191** 


247*** 


-.005 




°p<.10;*p<.0 


5; **p<.01; ***<.001 (2-tailed test) 





The mesosystem is characterized by the nature of the physical home environment 
and the parenting environment. According to the correlations shown in Table 5.5, there 
is a statistically significant relationship between the parenting and physical environments 
and behavior and development. Children with better behavioral and developmental 
outcomes tend to live in homes with more conducive parenting and physical 



77 

environments. The correlations for these measures, though statistically significant differ 
on the behavior and the development scales. The behavioral score has a higher 
correlation with the parenting (rho=0.387; p=0.000) and the physical (rho=0.324; 
p=0.000) environment than the development scale (rho=0.276; p=0.000; rho=0.237; 
p=0,000) respectively. It is possible that these small differences are due to the nature of 
the assessments, in that the behavioral assessment is conducted with the primary 
caregiver and an autonomous clinician conducts the developmental assessment. 

One might argue that the primary caregiver's assessment of the child and of the 
nature of their home environment is biased resulting in socially desirable scores and 
stronger correlations between the measures that are dependent on the caregiver's 
assessment. Yet, this argument does not hold true when looking at the relationship 
between the depression score and outcomes and the family social support score and 
outcomes. In both cases the correlations with the Bayley, which is determined by the 
clinician, are higher than the correlations with the Vineland, the interviewer and 
caregivers joint assessment of the child's behavior. Therefore at this point it is unclear 
why the correlations differ. 

The behavioral and the developmental assessments of children living in homes 
with a better quality of support are better than the assessments of children living in homes 
with less social support. Here, the developmental score correlates with the family social 
support scale at rho = 0.174 (p = 0.008) while the behavioral score is still significantly 
correlated but has a smaller coefficient (rho = 0.160) and higher p-value (p = 0.014). 

At the macrosystem level, the socioeconomic status of the family is related to the 
family's level of social support and to the nature of the home environment (see Table 



78 

5.5). Families living below the poverty level received lower scores on the physical 
measure of the home environment (rho=-0.396; p=0.000), on the parenting dimension 
(rho=-0.209; p=0.001) and on the family social support scale (-0.135; p=0.039). Of the 
dummy variables created to classify the families' social and economic background, the 
non-Black families living above poverty had the strongest correlation with the outcome 
measures. Non-Black children living above poverty are more likely than the other groups 
of children to receive higher scores on the Vineland behavioral assessment (rho=0.191; 
p=0.003) and on the Bayley developmental scale (rho=0.247; p=0.000). In contrast, 
Black children have poorer developmental outcomes when they also live in poverty 
stricken households. Yet, Black children who live above the poverty line tend to score 
lower on the behavioral scale. The race-class effect observed here shows the complexity 
of the relationship between socioeconomic status and outcomes. This relationship is 
explored further in the subsequent chapter. 





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80 



Multidimensional Model of Behavior and Development 

The primary hypothesis presented in this study is that, regardless of children's 
cocaine exposure status, the postnatal environment is a significant predictor of behavioral 
and developmental outcomes for pre-school aged children. This hypothesis is based on a 
compensatory theory of resilience and Bronfenbrenner's ecological theory of human 
development (see Chapter 3 for more detail). Based on the results from the bivariate 
analysis, it is clear that the neonatal and postnatal environment are significantly related to 
children's outcomes, whether they have been prenatally exposed to cocaine or not. In the 
following section, I use multivariate analysis to examine the relative contributions of 
biomedical, behavioral, and social factors on early childhood outcomes. 

For the sake of simplicity, behavior and development have been examined 
comparatively throughout the bivariate analysis. However, behavior, as a construct is 
different from development. According to Ribes (1996), behavior has been used to 
explain the process of development, while development has been defined as the 
qualitative changes in behavior. The concept of behavioral development was introduced 
in the 1950s under the rubric of social learning theory. Since that time, theories about the 
behavioral and developmental processes have been developed and tested by sociologists, 
behaviorists, psychologists, biologists, ecologists, and so on (see Bijou and Ribes 1996 
and Lerner 1983 for historical perspective). Roberts, Maddux, and Wright (1984:57) 
define the process of development as a process of systematic and measurable changes in 
behavior that occur "across the life span- from the prenatal period through life to death." 
In this vein, this research explores how prenatal, neonatal, and postnatal changes impact 
behavior and development, two processes that are significantly correlated. In this 



81 

research, I do not contend that development causes behavior, but the relationship between 
behavior and development is definitely worth exploring in future studies of "at-risk" 
children. 

Behavior 

In this study behavior refers to the intentional or unintentional actions exhibited 

by children as they learn how to adapt to their surroundings. The Vineland Adaptive 
Behavior Scale specifically measures the children's ability to demonstrate skills and to 
perform tasks that are necessary components of social interaction and individual survival. 
The behavior of children who have been prenatally exposed to cocaine has been of 
particular interest to those who care for these children at home and in public institutions 
because of the presumed behavioral problems associated with prenatal cocaine exposure. 
The early childhood behavior of this group of children is assumed to be a proxy for later 
life behaviors that may be problematic. 

Among the children included in this study, prenatal cocaine exposure does not 
appear to be related to behavior. There are no significant differences between the PCE 
children and non-PCE children. Indeed the bivariate regression model is not significant. 
In model 2, adding a second biomedical component (i.e. neonatal risk) makes the model 
significant. Higher neonatal risk of physiological complications is associated with lower 
behavioral scores (see Table 5.7). Prenatal cocaine exposure is not correlated with 
adaptive behavior and it is not predictive of behavior in the final multivariate model. In 
Table 5.7, the multidimensional model (Model 3) is compared to the biomedical model 
(Model 2). Adding social contextual factors significantly improves the models fit and the 
explained variance. 






82 



The strongest predictor of adaptive behavior is the mesosystem, specifically, the 
nature of the parenting environment (Beta =0.278; p= 0.000). Adaptive behavior scores 
are highest among children who have a positive parenting environment. The neonatal 
environment is the second strongest predictor in the multidimensional model of behavior. 
Children who had greater neonatal risk tend to have lower behavioral scores three years 
later (Beta =-0.172; p=0.004). Last, Model 3 indicates that Black children living above 
the poverty line have poorer adaptive behavior than the below-poverty Blacks (Beta=- 
0.165; p=0.009). It is interesting to note that non-Blacks living above and below poverty 
have more similar behavior scores than poor Black children. 

In the bivariate analysis, the families' level of social support and the quality of the 
physical home environment were significantly correlated with behavior, but they did not 
maintain their strength in the multivariate analysis. In general, the neonatal environment 
and aspects of the postnatal environment are significant predictors of behavior regardless 
of cocaine exposure status (Incremental F=7.292; p<0.001). 






83 



Table 5. 7: Multidimensional Models of Adaptive Behavior and Development, 
Standardized Regression Coefficients (p-values), n=234 




Vineland Adaptive Behavior 
Scales 


Bayley Scales of Infant 
Development 


Variables 


1 


2 


3 


4 


5 


6 


PRENATAL RISK FACTOR 


Cocaine 
Exposed 


0.087 
(0.187) 


.087 
(0.173) 


0.093 
(0.117) 


-0.012 
(0.851) 


-0.011 

(0.860) 


-0.019 

(0.755) 


NEONATAL HEALTH FACTOR 


Hobel 
Neonatal 


— 


-0.218 
(0.001) 


-0.172 
(0.004) 


— 


-0.268 
(0.000) 


-0.254 
(0.000) 


POSTNATAL SOCIAL FACTORS 


Depression 
Scale 


— 


— 


-0.022 
(0.715) 


— 


— 


-0.108 
(0.089) 


Parenting 
Environment 


— 


-- 


0.278 
(0.000) 


— 


— 


0.175 
(0.022) 


Physical 

Home 

Environment 






0.129 
(0.120) 






-0.013 
(0.877) 


Family 

Social 

Support 






0.093 
(0.133) 






0.140 
(0.030) 


Black Above 
Poverty 


— 


— 


-0.165 
(0.009) 


— 


— 


-0.044 
(0.499) 


Non-Black 

Below 

Poverty 






0.037 
(0.534) 






0.065 
(0.299) 


Non-Black 

Above 

Poverty 






0.071 
(0.292) 






0.181 
(0.010) 


R^ 


0.007 


0.055 


0.254 


0.000 


0.072 


0.194 


F 


1.751 
(0.187) 


6.723 
(0.001) 


8.495 
(0.000) 


0.035 
(0.851) 


8.974 
(0.000) 


5.993 
(0.000) 


Incremental 
F 


Between 
Model 

3&2 


7.292 


Between 
Model 
6&5 


4.8436 



Development 

Like behavior, there are numerous ways of measuring development. 
Development can be defined in broad or narrow terms. In this study, the Bayley Scales of 
Infant Development are used to measure the development of each child's mental and 



84 

motor skills. Development refers to children's achievement of particular growth 

parameters in relation to their chronological age. Development is the process of growing 

and reaching physiological maturity. From a biomedical standpoint, development is a 

physiological process, but when placed within the context of the social environment, the 

physiological processes can be directly or indirectly influenced by external factors. 

The Bayley measures the child's fine and gross motor skills, abstract reasoning, 

memory, learning and problem solving abilities. These domains reflect 

neurodevelopmental functioning, an area that can be compromised by the injection of 

cocaine (see Lauder 1991; Spear, Kirstein, Frambes 1989; Dow-Edwards 1991). 

According to Mayes and Bornstein (1995:253): 

Cocaine influences brain development directly through effects on developing 
neurotransmitter systems critical to neuronal differentiation and brain structure 
formation and indirectly through effects on blood flow to the developing fetal 
brain. . . Cocaine blocks the reuptake of dopamine, norepinephrine, and 5-HT by 
the presynaptic neuron [Swann, 1990], a process that is primarily responsible for 
inactivation of neurotransmitters. 

There are certain parts of the brain that are insensitive to the effects of cocaine, 
but in fetal brain development, the effect cocaine has on the monoaminergic 
neurotransmitters is critical to brain structure and neuronal formation. Therefore, 
prenatal cocaine exposure places children at risk of poor neurodevelopmental 
functioning. Poor neurodevelopmental functioning can affect children's ability to react to 
stimuli, modulate arousal, and regulate their attention (Mayes and Bornstein 1995). 

In the multivariate analysis shown in Table 5.7, prenatal cocaine exposure is not a 
significant predictor of development in any of the models. Similar to the behavior 
models, the first model (Model 4) is unremarkable. Model 5 shows the impact of adding 
in an additional biomedical factor. The model itself is significant and it explains 7.2% of 












85 

the variance compared to Model 4 where prenatal cocaine exposure does not explain any 
of the variability in development. Similar to the behavior model, children with higher 
neonatal risk tend to have lower developmental outcome scores. The final model, in 
which the social factors are added, is a significant improvement over the biomedical 
model (Model 5). The strength of the neonatal risk score changes very little when the 
postnatal factors are added. The addition of postnatal environmental factors enhances our 
understanding of development by explaining nearly 20% of the variance in development, 
which is nearly three times more than what the biomedical factors explained alone. 

Of the postnatal factors included in the multidimensional model, there are 
significant effects from the micro-, meso-, exo-, and macro dimensions of the social field. 
At the microdimension, children whose primary caregivers have higher levels of 
depression are marginally more likely to have lower developmental scores (Beta = - 
0.108; p = 0.089). At the mesodimension, again the parenting environment is associated 
with developmental outcomes (Beta = 0.175; p = 0.022). However, the physical home 
environment, which was correlated with development in the bivariate analysis, is no 
longer significant in the multivariate analysis (Beta = -0.013; p = 0.877). In contrast to 
the behavior model, family social support is significantly associated with development 
(Beta = 0.140; p = 0.030). Specifically, children with higher development scores live 
with caregivers who have a more helpful social support network. Non-Black children 
living above poverty have significantly higher scores on the Bayley than the poor Blacks 
(Beta = 0.181; p = 0.010). Both poor non-Blacks and non-poor Black children have 
developmental scores similar to poor blacks. This means that social class shapes 



86 

developmental score differences among non-Blacks, but not among Blacks. The macro 
dimension also works differently for behavioral and developmental outcomes. 

Summary 

In conclusion, each dimension in the multidimensional model explains some 
portion of the variability in development and in behavior. The neonatal environment is 
the strongest predictor of outcomes, while the postnatal environment adds to our 
understanding of behavioral and developmental differences among children who are 
considered to be "at-risk" of early childhood delays. In the multivariate analysis, poor 
neonatal health and postnatal social and economic disadvantage place these children at 
greater risk for poor behavioral and development outcomes, while fewer neonatal 
complications and a positive home environment full of social support compensates for 
those risks. 

The fact that there are no statistically significant differences between the children 
who were and who were not prenatally exposed to cocaine does not mean that children 
who have been prenatally exposed to cocaine are not "at risk." As indicated by their 
mean scores on the behavior and development scales, on average the PCE and non-PCE 
children from this at-risk sample scored below normal (< 100) on both scales. The lack of 
a significant difference between the two groups does indicate that factors other than 
prenatal cocaine exposure either help or hinder the development of positive early 
childhood outcomes. The sample of children in this study represent a group of children 
who are at risk of poor outcomes due to socioeconomic disadvantage, which is related to 
familial instability, poor parent-child interaction, maternal depression, and insufficient 
family and social support. The problems associated with prenatal cocaine exposure, 






87 

such as lower birth weight, perinatal health complications, and prematurity were not 
profound. 

Again, the social and environmental factors considered in the multidimensional 
model were stronger predictors of outcomes for children at age 3 than their risk of 
prenatal cocaine exposure. In the concluding chapter, I expand upon these findings and I 
discuss their social and political implications for prenatally cocaine exposed children, 
their biological mothers, and the many people who care for them. 






CHAPTER 5 
RISK AND RESILIENCY IN EARLY CHILDHOOD 



Early Childhood Risk 
Prenatal Cocaine Exposure 

The goal of this research has been to identify the relative influence of the prenatal, 
neonatal, and postnatal environments on the behavior and development of pre-school 
aged children. The children included in this study have been deemed "at-risk" because of 
their prenatal cocaine exposure. Specifically, this research has been designed to 
determine the effect that prenatal cocaine exposure, a prenatal risk factor, has on early 
childhood outcomes. As a whole, literature on prenatally cocaine exposed children is 
inconclusive due to contradictory results reported in the biomedical and behavioral 
literature. 

The biomedical literature has taken on a teratogenic approach that focuses on the 
physiological effect cocaine has on the fetus and developing child. This problem-seeking 
approach presupposes that cocaine exposure has a direct organic effect on prenatally 
exposed children that will negatively influence later stage development. The biomedical 
model is limited because it typically fails to consider the social and environmental factors 
that can enhance or hinder behavior and development. The behavioral studies have tried 
to compare the behavioral and developmental outcomes for PCE and non-PCE children, 
which is difficult because of the methodological issues surrounding the study of prenatal 



88 






89 

cocaine exposure and its long-term effects. In this research, I have attempted to address 
some of the concerns raised by previous researchers through the use of a prospective, 
longitudinal research study and a multidimensional theoretical model that incorporates 
the tenets of the biomedical, behavioral, and social sciences. 

The findings presented in chapter 5 demonstrate the utility of a multidimensional 
approach to the study of prenatal cocaine exposure. Clearly, the combination of 
biomedical and sociological factors adds to our understanding risk and resilience among 
this group of children. In this multidimensional model, prenatal cocaine exposure served 
as the primary risk factor, yet it was not a significant predictor of outcomes. Prenatal 
cocaine exposure did not predict behavior or development when it was the only variable 
in the model or when it was compared to the other biomedical risk in the neonatal 
environment or the compensatory factors found in the postnatal environment. 

The assessment of neonatal health complications, an indicator of future health 
problems, and the nature of the parenting environment were consistently correlated with 
behavior and with development in the bivariate and multivariate analyses. Children who 
experienced fewer complications neonatally had higher scores on the behavior scale and 
the developmental assessment. Additionally, the children living in more positive 
parenting environments with greater warmth and acceptance and more nurturing received 
higher scores on both scales. 

Behavioral and developmental outcomes were affected differently by the other 
dimensions of the postnatal environment, including the primary caregivers' risk of 
depression, the physical condition of the home, the families' social support network, and 
the socioeconomic status of the families. The difference between behavior and 



90 

development was an unanticipated result. I had hypothesized that behavior and 

development would follow the same pathway. I developed this hypothesis as a means of 

testing the relationship between behavior and development, particularly as they relate to 

the popular beliefs about prenatally cocaine exposed children. 

Children who have been prenatally exposed to cocaine have been characterized as 

exhibiting poor and often times extremely problematic behavior (Bendersky & Lewis 

1998; Calhoun 1996; Howard, Williams, & McLaughlin 1994; Neuspiel 1993). The 

concern for the behavior of prenatally cocaine exposed children alludes to a relationship 

between behavior and development. It is presumed that children's prenatal exposure to 

cocaine has an impact on their physiological or neurological development resulting in 

their inability to regulate their behavior. Several researchers have found that cocaine has 

a direct and an indirect effect on the developing fetus and infant. These studies 

conducted on animals and infants have found a relationship between cocaine exposure 

and brain development, but they have not identified the direct or the long-term effects of 

the exposure. The following statement by Lester, Freier, and LaGasse (1995: 24) in an 

article titled "Prenatal Cocaine Exposure and Child Outcome: What Do We Really 

Know?" illustrates this point: 

. . . cocaine has a specific direct effect on brain function and an indirect 
effect through the influence of fetal nutritional status and it is possible that 
these direct and indirect effects have different influences on 
neurobehavioral functioning. 

The work done by Lester and his associates reminds us that there are still a lot of 
unknowns when it comes to the effect of prenatal cocaine exposure. Lester and his peers 
conclude their analyses of the research on PCE by stating that "like prematurity, drug 
exposure can be viewed as another potential insult or injury to the developing fetus." For 



91 

some children it may have a profound effect and for others it may not affect them at all 
(Lester, Freier, & LaGasse, 1995: 32). Thus, the singular focus on prenatal cocaine 
exposure as the cause of behavioral and developmental problems for this group of 
children has diverted attention away from the more significant influences on these 
children's lives. 

Poor Neonatal Health 

The children included in this study of prenatal cocaine exposure exhibited a 

considerable number of neonatal health complications as compared to the norm. On 
average, both the PCE and the non-PCE children received approximately 15 points on the 
Hobel neonatal risk assessment. According to Hobel (1979), a score of 10 or higher is 
indicative of future health complications including a greater risk of premature mortality. 
Unlike, prenatal cocaine exposure, the biomedical health risk determined at birth was a 
significant predictor of behavior and development. The children with higher risk 
exhibited more behavioral and developmental problems. 

This finding confirms that there is a direct relationship between biomedical 
factors and developmental outcomes. Even though the correlation between the neonatal 
risk and development was not strong, it was significant. Moreover, a relationship 
between neonatal risk and development does exist. Yet, even more convincing is the 
multivariate analysis that shows a reduction in the predictive validity of the 
developmental model when the social ecological factors are added. The neonatal health 
risk is a strong and significant predictor of development and it gets stronger when 
controlling for social ecological factors. 

Again, this is not true for behavior. The biomedical health risk of the neonate is a 
significant predictor of behavior, but when controlling for the social ecological factors 



92 

that comprise the postnatal environment, the relationship between behavior and the 
neonatal environment is not as strong. The multidimensional model that includes the 
prenatal, neonatal, and postnatal factors explains a higher percentage of the variability in 
behavior than it does in development for this group of children. 

These findings raise questions about whether or not behavior and development 
are inextricably intertwined. If biomedical factors do not have as large of an impact on 
behavior as they do on development and biomedical factors have less of an impact than 
social ecological factors, then how do we explain the problem behavior attributed to "at- 
risk" children? The "at-risk" child's exposure to prenatal and neonatal health risk does 
not serve as a sufficient explanation for poor behavioral outcomes, hence there is utility 
in taking a multidimensional approach that integrates biomedical, behavioral sociological 
risk factors. 

Maternal Depression 

Research has shown that psychological well-being is a significant predictor of 

poor health outcomes for children and pregnant women. Children of depressed mothers 
are more likely to suffer maltreatment and abuse (Kotch, Browne, Ringwalt, Stewart, 
Ruina, Holt, Lowman, and Jung 1995). Studies have also shown that women who suffer 
from depression are more likely to have problems consoling their children during times 
of distress, thus limiting the establishment of positive parent and child interaction 
(Zuckerman, Bauchner, Parker, and Cabral, 1990). Pregnant women who suffer with 
depression experience more complications during pregnancy resulting in poorer health 
outcomes for the mother and her child (Kitamura, Sugawara, Sugawara, Toda, and Shima 
1996). 



93 

In this study, the biological mothers and the primary caregivers of the children at 
age three, have a considerable risk of suffering from depression. At birth, both the 
biological mothers who used cocaine and the non-cocaine users demonstrated a risk of 
experiencing moderate depression based on their mean score of 27 on the Center for 
Epidemiologic Studies-Depression (CES-D) scale (Wobie, Eyler, Behnke, & Conlon 
1997). At age three, the mean score for both groups of primary caregivers was a little 
lower (mean =21) than the biological mothers' scores at the time of the child's birth, but 
it was still within the range for risk of moderate depression. The caregivers of the PCE 
children reported significantly lower scores than the primary caregivers of the non-PCE 
children demonstrating a pronounced improvement in the psychosocial status of the 
caregivers of PCE children overtime. 

The change in the psychosocial status reflects a change in the biological mothers' 
status as the primary caregiver. By age 3, nearly half (49.5%) of the children who were 
prenatally exposed to cocaine are no longer living with their biological mothers. This 
differs considerably from the non-PCE group. The non-PCE children are more likely to 
be living with their biological mother, who is at greater risk of depression and comes 
from a low socioeconomic background, both of which place the children at risk of poor 
early childhood outcomes. The PCG's psychosocial status is an important component in 
the multidimensional model of behavior and development, because of the impact it has on 
parent-child interaction. 

It is perhaps, because of the interaction between maternal depression and the 
parenting environment that it was not a significant predictor in the multidimensional 
models of behavior or development. The primary caregivers depression status was 



94 

significantly correlated with the measures of the home environment and the home was 
significantly correlated with behavior and development even when controlling for 
socioeconomic status and family support, the other postnatal factors. It is believed that 
the change in the primary caregivers of the prenatally cocaine exposed children not only 
reduced their risk of living with a depressed caregiver, but it has contributed to an 
improvement in the home environment. Although, we must not forget that the 
environment of this group of children is still not stellar, but it has improved. 

Low Socioeconomic Status 

In addition to the risk caused by prenatal cocaine exposure, health complications, 
and maternal depression, the children in this study are at risk of experiencing the 
deleterious effects of socioeconomic disadvantage. Researchers across numerous 
disciplines, studying a variety of circumstances have consistently demonstrated a 
correlation between race and income. This study is no different. The Blacks in the study 
are more likely to have lower incomes than the non-Blacks. Blacks are more likely to 
live below the poverty level than non-Blacks. These findings are intuitive, yet the 
relationship between socioeconomic status and early childhood outcomes is not so clear. 

As mentioned earlier the pathway leading to positive behavioral outcomes 
differs from the developmental pathway. According to the multidimensional model, 
socioeconomic status is a stronger predictor of development than it is of behavior, but it 
is a significant predictor in both models. Poor children, regardless of race and Black 
children, regardless of income have poorer developmental outcomes than non-Black 
children living above the poverty line. Hence, poverty is also a significant predictor of 
developmental outcomes for this group of "at-risk" children. This could potentially be 



95 

explained by the fact that access to economic resources improves one's access to health 
care and in the developmental model, poor health is a sure sign of poor development. 

Yet, the road to adaptive behavior is a little more complicated. The black children 
living above poverty appear to have poorer outcomes than Black and non-Black children 
living below poverty and non-Black children living above poverty. What this implies is 
that impoverished children and non-Black children have acquired more adaptive behavior 
skills than Black children who are living above the poverty line. What does this mean? 
Is race not a risk factor for poor behavior? Does being poor improve behavioral 
outcomes? In the bivariate analysis, race is significantly correlated with behavior, but 
income is not correlated with behavior. The correlation between race and behavior 
indicates that Black children tend to score lower on the adaptive behavior scale than non- 
Black children. 

This research does not allow me to explain this anomaly, but it does question the 
relationship between poverty and behavior. Of the many conclusions that could be 
drawn, two come to mind: (1) perhaps, being poor places you at a greater risk of 
receiving a label that indicates behavioral problems, whereas poverty is not necessarily 
the cause of the problem and/or (2) poor children and non-Black children living above 
poverty may have greater access to services that encourage behavior modification and 
early childhood development, such as Head Start, pre-school, and other compensatory 
factors. The latter conclusion is well supported in the child abuse literature that has 
found a significant correlation between poverty and a families involvement with social 
service programs and early childhood interventions (Edwards, Tripp, Purcell, Danda, & 
Evans 2001 ; Lee & Goerge 1999). While the former theory about the effects of labeling 



96 

children has been supported by research on the self-fulfilling prophecy and other micro- 
level sociological theories (Allport 1988; Archibald 1992; Merton 1948). 

Producers Of Resilience 
Positive Parenting 

Positive or healthy family functioning is a key factor in the resiliency research 
that addresses the needs of young children (Barnard 1994; Beardslee, Swatling, Hoke, 
Rothberg, Velde, Focht, and Podorefsky 1998; Beardslee, Wright, Salt, Drezner, 
Gladstone, Versage, and Rothberg 1997; Rak and Patterson 1996; Tarwater 1993). In 
poor families where the key players are a single mother and her child, positive family 
functioning is determined simply by the quality of parent child interaction. Mothers, or 
in the case of the families in this sample, primary caregivers who exhibit positive parent- 
child interaction through warmth and acceptance and the provision of academic 
stimulation, are rearing children who receive higher scores on the behavioral and the 
developmental assessment than their peers who are living in homes that are less 
nurturing. 

The existence of a positive parenting environment enhances the behavior and 
developmental outcomes for the children in this study. The parenting environment is a 
better indicator of positive outcomes than the condition of the physical environment; 
demonstrating that the quality of the relationships inside of a home outweighs the 
quantity of material possessions found within the home. On a scale of to 6, with 6 
being the highest score, the average score on the parenting dimension is 4 meaning both 
the PCE and non-PCE children are living in homes that are slightly above average on the 



97 

parenting dimension, a dimension that is a significant predictor of behavior and 
development. 

It is the strongest predictor of behavior in the multidimensional model. It is 
preceded by biomedical risk and the families' socioeconomic status in the developmental 
model. Therefore, children who are "at-risk of poor developmental outcomes because of 
physiological problems that may be exacerbated by poverty have the potential for 
reducing the problems caused by their poor health and impoverished status, by being 
placed in homes with caregivers who provide the children with warmth, acceptance, and 
encouragement. 
Family and Social Support 

Last, resiliency can be produced by not only enhancing the interaction between 
the primary caregiver and the child, but by enhancing the relationship between the 
primary caregiver and her peers. Family social support is a significant predictor of 
development among the children in this study. It is not a statistically significant predictor 
of behavior, but it is positively and significantly correlated with behavior and 
development in the bivariate analyses. For development, an increase in the quality of the 
social support available to the primary caregiver results in predictably higher scores, even 
when controlling for the other postnatal factors. In the behavioral model, family social 
support loses its significance when controlling for other predictors. 

Taylor (1996) found that the support provided by kin was directly related to 
family organization and functioning, two factors that were directly related to behavioral 
outcomes for African-American adolescents. The parents who were able to draw upon 
the support of extended family were also more likely to be involved with their children's 
activities and the parents and the children expressed less psychological distress. For 



98 

these families, the number of problem behaviors exhibited by the child was significantly 
less (Taylor 1996). These findings point to the long-term impact family social support 
may have on the children in this study. It is not the strongest predictor of outcomes, but 
the results form the bivariate and multivariate analyses demonstrate a trend where family 
social support is a factor worth considering, because of its close association to maternal 
depression and the home environment, factors that clearly predict outcomes for pre- 
school aged children. 

In this study social support is a measure of the primary caregivers perception of 
how helpful her extended family, the child's extended family, and social and professional 
agencies have been to her over the past year. According to Dolbier and Steinhardt 
(2000), the perception of support can be linked to health outcomes, the families' ability to 
deal with stressful life events, and one's psychological well-being. Therefore, as 
practitioners and interventionists begin to look at ways of improving the physiological 
and the psychological well-being of the women who care for "at-risk" children, it is 
important to consider the role extended family and external social supports can play in 
their lives. 

Interventions And Implications 

The multidimensional approach that has been examined in this study has helped 
explain the relationship between the biomedical aspects of the prenatal and neonatal 
environment, in addition to the social ecological characteristics of the postnatal 
environment and how these dimensions affect the behavior and development of a group 
of "at-risk" children. The multidimensional model has proven to be a considerably useful 
tool in explaining the biomedical, behavioral, and sociological pathways of development. 



99 

Biomedical risks can hinder the development of socially and economically disadvantaged 
children who do not have the benefit of a positive home environment that is surrounded 
with quality social support. The behavior of these children depends on the nature of the 
parenting environment and the relative risk of health related complications at birth. 

These findings imply that children who have been prenatally exposed to cocaine 
are not doomed, but that they are resilient. Their resiliency depends on the reduction of 
postnatal health and social ecological risks. The practical implications of this research 
include the use of a wholistic perspective when developing and implementing 
interventions for pregnant drug users and their children. Low income women who suffer 
with depression and limited social and/or economic resources who become pregnant are 
"at-risk" of using cocaine and other drugs. Their pregnancy tends to complicate the 
situation. The problems associated with their impoverished status, depressive 
symptomology, and drug use can be passed on to their children in the form of prenatal, 
neonatal, and postnatal risks. Therefore, the multiple needs of the mother need to be 
addressed, as do the multiple needs of the child. 

Interventions need not only include the child who is either exhibiting problems or 
is at risk of experiencing problems, but they need to include the biological parents and/or 
the child's primary caregiver, and the institutional supports available to the family. In 
order to design an intervention that addresses multiple audiences with multiple needs the 
design team needs to be interdisciplinary. Thus the theoretical implication of this work is 
to promote interdisciplinary research and teaching. Researchers need to cross their 
disciplinary boundaries by incorporating the sound principles of the biomedical, 
behavioral, and social sciences in their work. Educators need to collaborate with one 



100 

another as a means of identifying the best practices in their fields that can be reproduced 
in their scholarly work and their training of practitioners and future scholars. 

Limitations And Recommendations 

As in any research the recommendations presented in this study are confined by 
the limits of the data. The data that support the utility of a multidimensional approach to 
the study of prenatal cocaine exposure and the creation of evidence-based interventions 
comes from a research project that has a sound methodological and theoretical 
foundation, but limited data. The sample size is relatively small and non-representative 
of this country's social demographics. 

The majority of the children included in the study are African-American, poor, 
and living in communities that range from rural to suburban based on population size and 
geographic location. Therefore, it is not possible to assume that the findings presented 
here will automatically be reproduced in a study that utilizes a different sample of 
children and families. However, it is safe to say that among this group of 'at-risk" 
women and children there are multiple dimensions of influence on the children's 
outcomes at age three and the saliency of the risk and resiliency factors introduced in this 
study are worth exploring in future research studies that involve this sample and others. 

Because this study only uses a cross section of the data collected during a 
longitudinal study on prenatal cocaine exposure, it fails to contribute to our 
understanding of how biomedical, behavioral, and sociological factors influence cocaine 
exposed children's entire life course trajectory, but this study will begin a long discussion 
on the multiple influences from the prenatal, neonatal, and postnatal environments on 
childhood and later life development. I invite other researchers to join the discussion and 



101 

participate in the production of practical solutions to the problems that face "at-risk" 
children and their families. 









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BIOGRAPHICAL SKETCH 

Carla Denise Armbrister Edwards began her academic career at the University of 
Pennsylvania where she received two degrees and graduated with academic distinction. 
In 1992, she received a Bachelor of Arts degree in sociology with a concentration in 
deviance and social control. One year later, she received a master's degree in education 
with a concentration in psychological services. Upon completing her master's degree, 
she pursued a career in higher education. She served one year as a Residential Instructor 
at the University of South Florida. Then in 1994, she began serving as an Assistant Dean 
in the College of Arts and Sciences at the University of Pennsylvania. 

As a native Floridian, Carladenise decided to return home to pursue her doctorate 
in sociology. She began working on her doctorate at the University of Florida in 1997. 
During her tenure in Gainesville, she served as a research assistant on numerous projects, 
a sociology instructor at the University of Florida and at Santa Fe Community College, 
and the project coordinator and co-principal investigator on the Healthy Families 
Jacksonville Evaluation Project. Presently, she is serving as a Presidential Management 
Intern in the Center for Mental Health Services in the Department of Health and Human 
Services in Rockville, Maryland. 

Carladenise is the wife of Herman A. Edwards, the daughter of Anthony and 
Juanita Armbrister, and the sister to the late Andrew P. Armbrister (deceased April 4, 
2001). Carladenise has been actively involved in Alachua County's Election Board, Big 
Brother-Big Sister of Philadelphia, and Zeta Phi Beta Sorority, Incorporated. 

115 



I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 

Barbara A. Zsfembik, Chair 
Associate Professor of Sociology 

I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 

Fonda Davis Eyler, £fl.D. 
Professor of Psychology 

I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




Leonard ] 
Professdr of S( 

I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




John Henretta, Ph.D. 
Professor of Sociology 

I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 



Terry L. Mills, Ph.D. 
Assistant Professor of Sociology 



This dissertation was submitted to the Graduate Faculty of the College of Liberal 
Arts and Sciences and to the Graduate School and was accepted as partial fulfillment of 
the requirement for the degree of Doctor of Philosophy 



December 2001 



sopny. a 



Dean, College of Liberal Arts and Sciences 



Dean, Graduate School